AFFIDAVIT OF ACCIDENT

I, FATIMA KAWTHAR M. ABAM, Filipino, of legal age, single and a resident of 57-c
jersey street Toro Hills Subdivision, Barangay Bahay Toroo, Quezon City, after having been
duly sworn to in accordance with law, hereby, depose and state:

That I am the driver of a Black Ford Ecosport registered in the name of INJIMAR U.
ABAM more particularly describe as follows:

Make/Model : Ford Ecosport

Color : Black

Plate No. : NBM 4998

Engine No. : UEJAHK33694

Model No. : 2018

On October 6, 2019 at around 7pm in the evening, I was driving along EDSA Cubao
northbound. In the same lane, a commercial bus was also traversing the road on my right side on
a fast speed. The bus tried to overtake me from my lane and in doing so it sideswiped the side
right portion of my driven vehicle. I tried calling the attention of the bus driver but to no avail.
Unfortunately, I was not able to neither stop the driver of the bus nor get the plate number of
the bus. The accident happened so fast and went beyond my control.

I am executing this affidavit to attest to the truth of the foregoing statement and in
support of my repair claims from the insurance company.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this ___day of _____________, 20___ at

________________, Affiant exhibiting to me her _________________________________
issued at _____________ on ________________.

Doc. No. ____;

Page No. ____;
Book No. ____; NOTARY PUBLIC
Series of ____;