Republic of the Philippines )

General Santos City ) S.S.

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AFFIDAVIT OF ACCIDENT

I, ERIC RENARD ALSULA ARMADA, of legal age, Filipino citizen, and a

resident of, Benigno Aquino Jr., Norala, South Cotabato, Philippines, after having
duly sworn to in accordance with law, do hereby depose and say;

1. I own a certain vehicle registered under my name, with the following

descriptions:

Make : Toyota
Engine No. : 1KD-9670244
Chassis No. : MR0YZ59G7-00038915
O.R. No. : 1844345915
Plate No. : SGL-957

2. On September 11, 2020, at Balmores St., City of Koronadal, I

accidentally opened the right door of my car, a tricycle approached from the
back and bumped the said door.

3. As a result, the car incurred damage.

4. The said incident was without fault or negligence on my part same as

with the driver of the said dump truck but purely accidental in nature.

5. I execute this Affidavit to attest of the truth of the foregoing facts, to

support for my claim of comprehensive insurance for the above-described
vehicle, to have it repaired and for all legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

________________ at General Santos City, Philippines.

ERIC RENARD ALSULA ARMADA

Affiant
Driver’s License: L04-08-006944

SUBSCRIBED AND SWORN to before me this ________________ at

General Santos City, Philippines. Affiant showed to me his Driver’s License
indicated above as proof of his identity

Doc. No. ____;

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