REPUBLIC OF THE PHILIPPINES )

CITY OF _________________________ ) S.S.

Affidavit of Car Accident

I, _____________________, of legal age, single and presently residing at
____________________________________________, after being sworn in accordance
with law, hereby depose and say that:

1. I am a the driver-user of ___________________ with plate number

_____________ registered under the name of ________________________;

2. On __________________ at around ____________, while I was driving said

motor vehicle from _____________ and going to ____________ passing
through _____________, I passed by the intersection, the portion where turning
right would lead to __________________________, a jeepney on the incoming
lane with very dim headlights, almost to the point of having no headlights at all,
suddenly hit my left side mirror at a moderately fast pace;

3. The incoming jeepney shattered the side mirror and punctured its shell. I was not
able to get the jeepney’s plate number as it immediately sped off towards
___________ and it was difficult to see its plate number due to not having any
lights thereon. All I could remember was that the jeepney’s color was yellow
with a relatively wide body;

4. That I am executing this affidavit to attest the veracity of the foregoing facts and
for whatsoever legal purpose it may serve.

Done this __________________ at ______________, Philippines.

____________________________
Affiant
__________________________

SUBSCRIBED AND SWORN to before me this ______________________ at

_____________, Philippines, affiant exhibiting to me his above provided competent
evidence of identity.

Doc. No. _____

Page No. _____
Book No. _____
Series of _____