Republic of the Philippines)

Quezon City )S.S.

AFFIDAVIT
I, Joyce R. Alcantara, of legal age, Filipino, and a resident of 33 Tirona St. Project
4, Quezon City after having been sworn in accordance with the law, hereby deposes and
states the following:
1. I am the owner of 2020 Honda BR-V, with corresponding Certificate of
Registration No. 38108627, and Official Receipt No. 1855023730, specifically described
as follows:
Make: Honda Series: BR-V Plate No: NGD 1553
MV File No. 1366-00000312225 Engine No.L15Z16723886
(“subject vehicle”);
2. That on ______________, at around ___________, I was driving the subject
vehicle. While I was traversing Col. Boni Serrano Avenue, Quezon City, the ______ side
mirror of the subject vehicle was hit by another vehicle with plate no. ____________ .
(“suspect”);
3. After the hit, the suspect did not stop and run away from the place of incident and
I actually tried to catch the former, but to no avail;
4. I am executing this Affidavit to attest to the truth of the foregoing and in support
of the claim against the insurer for the repair of the damage caused to my vehicle.

_________________________
Joyce R. Alcantara
Driver’s License No.___________/
valid until _____________

SUBSCRIBED AND SWORN to before me this _______________ at Quezon

City, Metro Manila, affiant exhibited to me her abovementioned valid Government ID.

Doc No.____
Page No.___
Book No.____
Series of 2022.