REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) S.S.

A F F I D A V I T OF A C C I D E N T

I, NOEL SABINIANO GORDO, of legal age, Filipino, with residence

and postal address at No. 137 Rendon St. Cabatuan Alaminus City,
Pangasinan, after having been duly sworn to, do hereby depose and
state:

1. That I am the driver of a Toyota Vios owned by JULITA DEMALATA

GORDO which is more particularly described as follows:

Make/Type : TOYOTA/SEDAN
Series : VIOS 1.3E GAS A
Model : 2018
Plate No. :
Engine No. : 1NRX300254
Chassis No. : PA1B19F3XJ4062547
MV FILE NO.: 1380-00001006379

2. That on July 02, 2021 at around 4:00 pm, I am safety driving

backward to park the aforesaid vehicle and unfortunately I
accidentally hit the stairs on my garage at No. 21 Pisig Nayon Brgy.
4 Caloocan City;

3. That due to that incident the car bumper had a dent and
scratches;

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

foregoing facts and to inform and claim from the Insurance
Company the damage caused by the said incident, attached
herewith is the Insurance Policy of said car together with all other
pertinent data and documents thereof.

IN TRUTH WHEREOF, I have signed this instrument this _______th

day of __________________ at Quezon City, Philippines.

NOEL SABINIANO GORDO

Affiant

SUBSCRIBED AND SWORN to before me this ___________ day of

_____________________ at Quezon City, Philippines. Affiant exhibiting his
Driver’s License No. N02-01-460599 with Expiry date on 2023/07/26
issued by LTO.

Doc. No.: _____________ NOTARY PUBLIC

Page No.: _____________
Book No.: _____________
Series of 2021