AFFIDAVIT OF ACCIDENT

I, ___________________, Filipino, of legal age, single/married, with address at

______________________, Philippines, after having been sworn in accordance
with the law, hereby depose and state that:

1. I am the registered owner of a ____________.

2. At around ___ am/pm of ___________, 20__, while I was driving the
aforesaid vehicle along _________ in _________ City,
______________________
3. All of a sudden ______________________.
4. I am executing this affidavit for purposes of attesting to the truth of the
foregoing, and for whatever legal purpose it may serve.

___________,____________,20__.

__________________

AFFIANT

SUBSCRIBED AND SWORN to before me this ____________________ at

_________________ affiant presenting to me his competent evidence of identity

by way of the following:

Name: ID with number issued on and valid until

Doc. No:__

Page No. ___

Book No.___

Series of 20__