REPUBLIC OF THE PHILIPPINES )

City of Batangas ) S.S.

AFFIDAVIT OF ACCIDENT

I, GORGONIA SIMBAHAN, Filipino, of legal age, married, with address at San

Antonio, San Pascual, Batangas, Philippines, after having been sworn in accordance with law,
hereby depose and state that:

1. I am the driver of a motor vehicle registered in the name of my husband, Porfirio

Simbahan. The motor vehicle is particularly described as follows:
a. Certificate of Registration No. 234568
b. Motor Vehicle File No. 54321
c. Maker: Subaru
d. Year Model: 2011
e. Engine No. 9856743286
f. Chassis Serial No. 09B99654KL90
g. Plate No.: PSJ 357
2. At around 2:00 AM of 5 September 2022, while I was driving the aforesaid vehicle
along Calansayan, San Jose, Batangas, when a motor vehicle was traversing the same
road in the opposite direction and on the same lane;
3. I timely swerved to the extreme right of the road, preventing a collision but side-
swept the aluminum guard rail situated along the edge of the shoulder of the
highway. Consequently, the motor vehicle was deeply scratched from the right front
fender to the right rear door;
4. This incident was not reported to the police and no estimate as to the amount of the
damage was made;
5. The motor vehicle is covered by a comprehensive insurance policy and will shoulder
the amount for the repairs subject to the payment of participation fee by the owner;
6. I am executing this affidavit for purposes of attesting to the truth of the foregoing,
and for whatever legal purpose it may serve.

15 September 2022

GORGONIA SIMBAHAN
Affiant

SUBSCRIBED AND SWORN to before me this 15 September 2022 at Batangas City

affiant presenting to me her PRC ID Card No. 98765 as competent evidence of identity.

Doc No.: 1
Page No.: 1
Book No.: 1
Series of 2022

ATTY. BENJAMIN LUKE PHILLIP G. VERDADDERO

Notary Public
Until December 31, 2022
PTR No. XXXXXXXX Jan. 3, 2022
IBP Lifetime XXXXX / Roll No. XXXXXX
Notarial Commission No. XXXX-XX-X / TIN XXX-XXX-XXX
MCLE Compliance No. XXXXX