Republic of the Philippines}

City of Davao }S.S

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AFFIDAVIT OF CAR ACCIDENT

I, MA AIDA GARZOTA SERGIO, of legal age, married, Filipino and

resident of Blk.9 Lot 9, Hades Celerina Heights, Cabantian, Davao City, after
having been duly sworn to in accordance with law, hereby depose and say that;

1. That I am the registered owner of motor vehicle described below;

Chassis Number : MRHDG1820HP001865

Engine No : L15Z13962994
Body Type : S-CUV
Make : HONDA
Plate No. : DV2984
Model Year : 2017

2. That on November 14, 2018 at about 10:30 am, while driving my car in
Cabantian Elementary School. I heard a broken windshield and I found out
that the windshield of my car was broken and was hit by a stone.

3. I am executing this affidavit to attest the truthfulness of the foregoing facts

and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, We have hereunto affixed my signature this

November 20, 2018 in the City of Davao Philippines.

MA AIDA GARZOTA SERGIO

Affiant

SUBSCRIBED AND SWORN to before me this November 20, 2018 in the

City of Davao. Affiant personally appeared and showing to me her Driver’s
License No.L02-17-003218.

Doc No.42;
Page No.10;
Book No.55;
Series of 2018