Republic of the Philippines )

City of Bacolod )S.S

AFFIDAVIT OF ACCIDENT

I, BEBSYL CHITONG GUMBAN MIRHAN, of legal age, single, Filipino

Citizen, and resident Bebot Trading, Hilado St., Villamonte , Bacolod City, Negros
Occidental, after having duly sworn in accordance with law depose and say:

1. That my sister, Clarice Joy Chitong Mirhan, of legal age, single, and resident
is a registered owner of RED MICA TOYOTA INNOVA YEAR MODEL 2021
which is more particularly described as follows:

OR NUMBER: 2007008581
CR NUMBER: 40503047
CHASSIS NUMBER: PA2JA8EMXL0084439
MV FILE NUMBER: 0601-000000923690
PLATE NUMBER: FAF 2959

2. That around 10 November 2022 in the evening, I drove the abovementioned

vehicle from Bago City to my father’s house in Florenceville Subdivision,
Barangay Singcang, Bacolod City;

3. That upon arriving in my father’s house in Florenceville Subdivision, the

parking was already full because there is a thanksgiving dinner at the said
house.

4. Upon parking at the corner area, I accidentally bumped the back of the
abovementioned car at the wall and cemented garbage bag;

5. That the said accident resulted to a damage of the abovementioned vehicle;

6. That I am executing this affidavit to attest the veracity of the foregoing

statements and for claiming my OWN DAMAGE as part of the
Comprehensive Insurance Policy of the Insurance Company.

IN WITNESS WHEREOF, I have currently affixed my signature this _______

day of NOVEMBER 2022 in the City of Bacolod, Philippines.

BEBSYL CHITONG GUMBAN MIRHAN

AFFIANT
DRIVER’S LICENSE NUMBER: F01-14-005810
Issued in: Bacolod City Expiry: 2032/03/02
 SUBSCRIBED AND SWORN to before me this ___ day of November 2022 in the
City of Bacolod, Philippines.

Doc No. ___

Page No.___
Book No. ___
Series of 2022.