Republic of the Philippines…)

City of Pasig )S.S

x…………………………….x

AFFIDAVIT OFF ACCIDENT

I Myra N Ragaza, Filipino, of legal age, married, currently residing at 234 Dr Pilapil Brgy
Pilapil Pasig City, Philippines, after having sworn to an oath and depose that;

1.0 I am the registered owner of a Mitsubishi Montero with plate number NEL7975.

2.0 At around 8:00 AM of June 2022, when my common law-spouse proceed at the pay
parking area at One Mercedes Plaza Parking Lot, Market Avenue, Brgy San Miguel
Pasig City, he discovered that the Wind Shield was broken.

3.0 Immediate thereafter, he then reported the incident to the duty Security Guard
Joevane Presidente and inquire the circumstances however, he averred that he had no
knowledge about it.Further, the incidents immediately reported to the nearest police
station and seek for Police Certification.

4.0 I am executing this affidavit for purposes of attesting to the truth of the foregoing and
for whatever legal purpose it may serve.

_______________________

__________________
Affiant

Republic of the Philippines)

City/Mun. of _______________) S.S.

BEFORE ME, a Notary Public, for and in ________________, this ___ day of
_____________ personally appeared _____________________________ who
presented to me their competent evidence of identity by way of
_____________________ issued at ____________________  on
____________________ all known to me to be the same persons who executed the
foregoing instrument and hereby acknowledged to me that the same is their free and
voluntary act and deed.

WITNESS MY HAND AND NOTARIAL SEAL.

NOTARY PUBLIC

Doc. No. ______

Page No. ______ 
Book No. ______
Series of ______