REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI )S.S

AFFIDAVIT OF CAR ACCIDENT

I, ROLDAN D. ELE, of legal age, Filipino, single and with residence address at
Sinki Agape PCU St., Brgy. 178, Caloocan City, After having been duly sworn to in
accordance with law, do hereby depose and state:

That I am the registered owner of a motorcycle vehicle more particularly

described as follows:

MAKE : Suzuki PLATE NO. : 834 PAA

YEAR MODEL : 2020 CR NO. : 41635013-0
CHASSIS NO. : BG41K-477266 OR NO. : 2057054123
MV FILE NO. : 1366-00000381235

That on 17 September 2021 around 6:00 in the morning, while I was going to
work along Rigalado Street Quezon City, I accidentally ran over a big dog that caused
me to out-balanced and fell over the said motorcycle vehicle. The motorcyle vehicle
sustained heavily damages from the broken right side head light and the left side mirror
snapped. Also, the foot rest of the motorcycle vehicle dented;

That the aforementioned situation was an accident beyond my control after

exercising extraordinary care and diligence to safety;

That I am executing this affidavit to attest to the truth of the foregoing facts and
for the circumstances of the accident and in compliance with the requirements of the
motorcycle vehicle insurer in respect to their claim damages.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 18 th day of

September 2021 at the City of Makati.

ROLDAN D. ELE
Affiant

Subscribed and sworn to before me this 18th day of September 2021 at the City of
Makati, and affiant exhibiting to me his Driver’s License ID No. N01-19-023075.

Doc No:_____
Page No:_____
Book No:_____
Series of 2021