Republic of the Philippines)

City of Zamboanga )s.s.

X----------------------------------X

AFFIDAVIT OF INCIDENCE

I, MAYMANA JANANG MUDDI, of legal age, married, Filipino citizen, and a

resident of Rosmin Compound, Putik-Tumaga Road, Zamboanga City, Philippines, after
having been duly sworn in accordance with law, hereby depose and say, that:

1. I am the registered owner of that certain motor-vehicle which is more particularly

described as follows, to wit:

MAKE : TOYOTA
SERIES : WIGO 1.0 G AT
ENGINE NO. : 1KRA593607
CHASSIS NO. : MHKA4DF5MJ057856
BODY TYPE : HATCHBACK
COLOR : BLACK

2. On 31 July 2021 at while I was maneuvering to park the abovementioned motor-

vehicle at GMS Oxygen and Acetylene Manufacturing located at Putik,
Zambaonga City, I misjudge my parking and hit an adjacent wall causing damage
to the front bumper abovementioned motor vehicle;

3. The damage caused upon the above-described motor-vehicle was not intentional
but purely of accidental cause;

4. I make these statements under oath and in good faith in order to establish the
fact that the damage caused was not intentional but purely of accidental cause;

5. I execute this Affidavit voluntarily to attest to the truth of the foregoing facts
based on personal knowledge and authentic records for purposes of Insurance
claim and other legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand on this 11 th day of August

2021 at Zamboanga City, Philippines.

MAYMANA JANANG MUDDI

Affiant
Non-Professional Driver’s License No.
J13-21-000815

SUBSCRIBED AND SWORN to before me on 11th day of August 2021 at

Zamboanga City, Philippines. Affiant exhibited to me his competent proof of identity as
written above.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2021.