Republic of the Philippines}

Imus City, Cavite }s.s

AFFIDAVIT OF VEHICULAR ACCIDENT

I, _________, of legal age, married and with residence address at
_________after having been duly sworn to according to law, hereby depose and state
That:

1. I am the driver of a motor vehicle which is specifically described as follows:

OWNER :
MODEL :
MOTOR NO. :
CHASSIS NO. :
COLOR :
PLATE NO. :

2. Said motor vehicle figured in an accident on July 1, 2016, at about

______pm/am while I was driving it along __________________ and as I was trying to
turn left at the corner of __________________________, an ______________ with
Plate No. ______ driven by a certain ____________ tried to overtake me in the inner
portion of that corner thus grazing and scraping the left hand fender liner, left hand side
view mirror, dents in the front and rear doors on the left hand side which thus sustained
considerable damage to my said vehicle.

3. As we were both in a hurry and I was still in my bedroom shorts as I was just
about to bring my daughter to school, we did not bother anymore to summon a
policeman to record the accident;

4. I am executing this affidavit in order to attest to the truth of the foregoing

circumstances and for the purpose of reporting the matter to my insurance office for
insurance claims.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of

__________, 2015 at the City of __________________.

____________________
Affiant

SUBSCRIBED AND SWORN to before me this __ day of ___________ 2015,

affiant exhibited a competent proof of their Identity:
Govt. Issued I.D. Valid Until
__________________ _______________________ ________________

Doc. No. __________;

Page No. __________;
Book No. __________;
Series of 2015.