REPUBLIC OF THE PHILIPPINES)

PROVINCE OF TARLAC ) S.S.

TARLAC CITY…………………… )

AFFIDAVIT OF SELF ACCIDENT

That I, FELIX SANTIAGO AGUSTIN, of legal age, Filipino citizen, and a

resident of Purok 5, Bantug, Guimba, Nueva Ecija, after having duly sworn to in
accordance with law, hereby depose and state - That:
1. I am the owner of a motor vehicle which is particularly described as follows:
MAKE AND MODEL: TOYOTA/2019
CHASSIS NUMBER: PA2JA8EM4K0060409
ENGINE NUMBER: 1GD0635567
MV FILE NUMBER: 0301-00001024115
PLATE NUMBER: CAQ6771

2. That on June 10, 2020 at 5 pm, I was maneuvering my car on the side of my
home residence. When I got off the vehicle to check the flairings on the side
of the bumper, I forgot to pull up the hand break. When I was about to get in
the car, the vehicle suddenly moved backwards causing the damage of the
back of the vehicle. Photos of the said damages are hereto-attached for
reference;

3. That I am executing this affidavit to attest to the truth of the foregoing

statement and in support of my claims for reimbursement from the insurance
company.

AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this
_________________ at Tarlac City, Philippines.

FELIX SANTIAGO AGUSTIN

Affiant

SUBSCRIBED AND SWORN to before me this, __________________ at

Tarlac City, Philippines.

Doc. No. _________;

Page No._________;
Book No._________;
Series of 2020.