Republic of the Philippines}

Manila City }s.s

AFFIDAVIT OF VEHICULAR ACCIDENT

I, Gem Alexandria T. Rivera, of legal age, married and with residence address at Hampstead Garden
Condo Sta Mesa Manila, after having been duly sworn to according to law, hereby depose and state:

1. That I am the asignee of a motor vehicle which is specifically described as follows: __

MODEL : TOYOTA VIOS

MAKE: SEDAN

COLOR : SILVER

PLATE NO. : NCW 1538

2. That said motor vehicle figured in an accident on November 5, 2022, At about 1pmwhile I was driving
it along President’s Ave Paranaque City and as I was cruising through a traffic road when a Toyota Hilux
with a plate no. DBA 2529, driven by Maricirs Arambulo, hit the rear of my car that left a huge
dent/damage on my trunk door .

3. As we were both in a hurry and I have my kids in tow, Maricris Arambulo gave me her contact number
and promised to cooperate.

4. That I am executing this affidavit in order to attest to the truth of the foregoing circumstances

and for the purpose of reporting the matter to my insurance office for insurance claims.

IN WITNESS WHEREOF, I have hereunto set my hand this 9th day of November, 2022 at the City

of Manila.

_______________________

Affiant

SUBSCRIBED AND SWORN to before me this __ day of ___________ 2022, affiant exhibited a competent

proof of their Identity:

Govt. Issued I.D. Passport no. P168780B Valid Until April 21, 2029

Notary Public

Doc. No. __________;

Page No. __________;

Book No. _______