REPUBLIC OF THE PHILIPPINES)

MAKATI CITY ) s.s.

AFFIDAVIT OF ACCIDENT

I, PERFECTO M. GARDE JR, of legal age, Filipino, married, and a resident of 2367
Antipolo Street Guadalupe Nuevo Makati City, after having been duly sworn to in accordance
with law hereby depose and say that:

1. On July 9, 2014 at 7:00 a.m. while parking my 2014 Toyota Altis model 2014
bearing Conduction Sticker- YA 9458 beside my house to avoid traffic;

2. I ACCIDENTALLY rammed the side gutter of the pedestrian walk way, causing my
car to suffer a disastrous damage;

3. The accident cause the driver side door panel underneath the driver’s side was
dilapidated, its bumper as well as its engine cover beneath the velocity bearing
was also damage;

4. Because of this, I immediately reported the incident to my insurance agent who

instructed me to prepare the necessary documents and submit the same in order for
me to claim the insurance for the consequent repairs thereon;

5. I am executing this affidavit to attest to the truth of the foregoing, and for all legal
intents and purposes it may serve.

IN WITNESS WHEREOF, I have here unto affixed my hand this ____ day of July 2014 at
_____________ City, Philippines.

PERFECTO M. GARDE JR
Affiant

SUBSCRIBED AND SWORN, to before me this _____ day of July 2014__________________

City, Philippines.

□ is personally known to the notary public

□ was identified by notary public through Competent Evidence of Identity as defined
by Rules of Notarial Practice of 2004, thru the presentation of the ff:

□ Drivers License No.GO6-93-029452 □ Passport No._____________

□ PRC No.______________________ □ TIN No. _________________
□ SSS ID No. ________ □ Company ID No.__________
□ GSIS ID No.___________________ □ CTC No.________________
□ Postal ID No.__________________ Issued on_________________
□ OTHER/S: __________ Issued in _________________

Doc. No. _______

Page No. _______ NOTARY PUBLIC
Book No. _______
Series of 2014