REPUBLIC OF THE PHILIPPINES)

IN THE CITY OF DAVAO . . . . .)S.S.

AFFIDAVIT OF ACCIDENT

I, _, of legal age, _, Filipino and a resident of _, Davao City, Philippines, after having
been duly sworn to in accordance with law, do hereby depose and state that:

1. I am a duly licensed driver with Non-Professional Driver’s License No. _ valid until _;

2. Around _, I parked the _ owned and registered in the name of my husband _ in _, Davao
City, particularly described as follows:

Make:
Plate Number:
Serial Number:
Motor Number:
Model:

3. When I returned to the aforementioned vehicle at _, I noticed a number of damages on

the vehicle, namely:

a.
b.

4. I had no personal knowledge as to the facts and consequences behind the damage, nor
was there any security personnel present to attest to the damage;

5. I am executing this Affidavit to attest to the truth of the foregoing and in support of the
claim against the insurer for the repair of the damage caused to the said vehicle.

IN WITNESS WHEREOF, I have hereunto set forth my hand this _ day of _ 2018 at
Davao City, Philippines.

_
Affiant
_

SUBSCRIBED AND SWORN TO BEFORE ME this _ day of _ 2018 at Davao City,

Philippines.

Doc. No.
Page No.
Book No.
Series of 2018