Republic of the Philippines}

Province of Cotabato }s.s

Kidapawan City }
x-------------------------------------x

AFFIDAVIT OF ACCIDENT

I, RENANTE ROMALDON PEPUGAL of legal age, married, Filipino, a resident of

Magpet, Cotabato, after having been duly sworn to in accordance with law, do hereby depose
and say:

That I am the owner of Toyota utility vehicle with Certificate Registration No.
344386291-1, Engine No. 1KRA488427 and Plate No. LAD-7353;

That the said motor vehicle was crushed or damage at the right portion on the day of the
incident on March 25, 2021 at 6:00 pm;

That as a result of said accident; the said Utility Vehicle was damage and needs repair;

That I am requesting that the said vehicle be repaired by the Committed Compassionate
Genuine Insurance where I acquired the same by Purchase on installment;

That I am executing affidavit to attest to the truth of the foregoing allegations.

IN WITNESS WHEREOF, I have hereunto set my hand below this 28th day of March
2022 at Kidapawan City, Philippines.

RENANTE ROMALDON PEPUGAL

Affiant
PDL: M06-11-003057

SUBSCRIBED AND SWORN to before me this 28th day of March 2022 at Kidapawan
City, Cotabato, Philippines. Affiant exhibited to his Identification Card Number indicated below
his name.

ATTY. OSCAR D. BAYOG

Doc. No. 80 Notary Public
Page No. 16 Until December 31, 2022
Roll No.18081
Book No. 05 IBP Life Time Member
Series of 2022. IBP OR No. 1009201/9-4-2015
O.R. No. 1012991/12-15-2015
PTR No. 2489090/01-10-2022
MCLE Compliance No. VI-0013914:Valid until April 14,2022
2/F GSP Building, Quirino Drive, Kidapawan City
Notarial Com. No. 132-2019