Republic of the Philippines}

City of Davao }S.S

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AFFIDAVIT OF CAR ACCIDENT

I, IVERSON WARNER DOLES IV, of legal age, married, Filipino and

resident of Blk.9, Lot 7, Phase 1, Pearl St., Hillside Subdivision, Davao City,
after having been duly sworn to in accordance with law, hereby depose and say
that;

1. I am the driver of a motor vehicle registered under the name of my wife

ROSALIE ROLLON DOLES:

Chassis Number : ____________________

Engine No : L2B163053120
Body : SEDAN
Mv File. : 1101-00000366584
Make : Chevrolet
Model Year : 2017

2. That on August 04, 2017 around 10:00 am in the morning, While I was
about to leave China Savings Bank Cm Recto, suddenly a Blue Jeepney coming
towards me, while trying to avoid collision, I hit the sign post causing damage
to my left rear passenger door, while the said jeepney, clipped my side mirror
causing damage thereof unfortunately, the jeepney did not even bother to
check the accident;

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

February 28, 2018 in the City of Davao Philippines.

IVERSON WARNER DOLES IV

Affiant

SUBSCRIBED AND SWORN to before me this February 28, 2018 in the

City of Davao. Affiant personally appeared and showing to me his Driver’s
License No.L02-14-016378.

Doc No.174;
Page No.35;
Book No.52;
Series of 2018