Republic of the Philippines)

Taguig City, Metro Manila ) S.S.

AFFIDAVIT OF ACCIDENT

  I, __________________________., of legal age, Filipino, and with residential

address at __________________________, after having been duly sworn to in
accordance with law, depose and state:

(1)  I am the owner of __________________________” with Plate No.

__________________________;

(2) That on or about 8 o’clock in the evening of

__________________________, I was driving the Van with the intention to park it in the
garage, unfortunately, I had very limited visibility at that time and the roads were slippery
to the heavy and intermittent rains;

(3) While attempting to park the Van in the garage, and suddenly noticed that
I was too close from the gate, and subsequently checked the rear right side of Van,
unfortunately, I accidentally sideswiped a portion of the gate post of the house garage
where the Van was parked; and

(4) That I am executing this affidavit for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of

___________, 2019 in Taguig City.

__________________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ___________, Metro

Manila, affiant exhibiting to me his _______________.

Doc. No.
Page No.
Book No.
Series of 2020.