REPUBLIC OF THE PHILIPPINES )

CITY OF DASMARIÑAS ) S.S

AFFIDAVIT OF ACCIDENT

I, KLEE R. DEMATAWARAN, of legal age, Filipino, and a resident of #88 Baron St.
Golden Gate Subd., City of Dasmariñas, Cavite after having been duly sworn to in accordance
with law, here depose and say:
1. That on 25 December 2021 while driving a motor vehicle registered in the name of my
mother, which is particularly described as follows:
Make/Type: Toyota Wigo
Model: 2018
Motor No.: 7M40-JGH4135
Chassis No.: OMGH46RR32C001391
Plate No.: FTW-004

2. That, at about 5:30 P.M., upon reaching Starfall Avenue corner Galesong St. in Makati
City, as I was trying to take a right turn towards Galesong St, a Yamaha Mio with Plate
No.: 313YMN driven by certain YOIMIYA NAGANOHARA tried to make a left turn from
the outer portion of the lane thus grazing and scraping the right-hand fender line which
thus sustained a considerable damage to my vehicle;

3. As we were both in a hurry, we did not bother to summon the police to record the accident;

4. That I am executing this affidavit in order to attest to the truth of the foregoing circumstance
and for the purpose of reporting the matter to the insurance office for insurance claims
IN WITNESS WHEREOF, I have hereunto set my hand this 22nd day of March, 2022, at the
City of Dasmariñas.
(SGD) Klee R. Dematawaran
Affiant
ID Type: Driver’s License
ID No.: K07-19-002453
Issued on: July 7, 2019
Issued By: LTO Dasmariñas

SUBSCRIBED AND SWORN to before me this 22nd day of March 2022, in City of Dasmariñas,
Philippines.

Doc. No.: 09 ;
Page No.: 01 ;
Book No.: 03 ;
Series of 2022