REPUBLIC OF THE PHILIPPINES )

PASIG CITY ) S.S.

AFFIDAVIT OF ACCIDENT

We, ERICK MAGPAYO y NIDEA, Filipino, of legal age, married, and residing at No.
110 Robles St., Manggahan, Pasig City, after having sworn in accordance with law, do hereby
depose and state that:

1. My wife, Rowena Magpayo, and I are the owners of Suzuki Swift Dzire with plate no.
UD 7880. The car, however, was registered under the name of my wife. As proof thereof
a copy of the OR CR is hereto attached as Annex “A”. ;

2. On or about 8:30 in the evening on March 30, 2017, we parked the said car in front of
Lucky Gold Plaza to buy something in a nearby grocery. However, when we went out of
Lucky Gold Plaza to get our car, we found out that there was a dent and several scratches
in our car;

3. The barker told us that a tricycle sideswiped our car while the same was parked in front
of the Lucky Gold Plaza. Unfortunately, the barker was not able to get the plate number
of the tricycle;

4. I am executing this Affidavit to attest to the truth of the foregoing facts and for whatever
purpose/s it may duly serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, we hereby affix my signature this 31st day of March 2017 at
Pasig City.

ERICK N. MAGPAYO

Affiant

SUBSCRIBED AND SWORN to before me this 31st day of March 2017 in Pasig City,
Philippines, affiant exhibited to me as competent evidence of identity his Professional Driver’s
License with No. D19-04-000956 issued by the Land Transportation Office.

ATTY. MARCELINO C. ARCE, IV

Public Attorney II
Notary Public
(pursuant to RA 9406)

Doc. No._____;
Page No._____;
Book No. _____;
Series of 2017.