Republic of the Philippines )

Municipality of Norzagaray )
Province of Bulacan )Sc.

AFFIDAVIT OF ACCIDENT

I, ______, of legal age, single, Filipino Citizen, and presently

residing at Poblacion, Norzagaray, Bulacan, after having been duly sworn
to, in accordance with law hereby depose and state:

1. That I am the registered owner of a Motorcycle bearing a Plate

No. 504, covered by Certificate of Registration No. by the Land
Transportation Office;

2. Last February 23, 2023, while I was driving along Dońa

Remedios Trinidad on my way to work, a dog suddenly appeared and
crossed the road, causing me to hit the same;

3. Due to the said incident, my motorcycle was damaged;

4. That said motor vehicle was insured by Liberty Insurance

Corporation with Policy number;

5. That I am a holder/possessor of a Professional Driver’s

License at the time of the incident; hence, I have the authority to drive
and operate the said vehicle;

6. That I am executing this affidavit to attest to the truth of all the

foregoing facts and circumstances and for all legal intents and purposes
that it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 14th

day of April 2023, hereat Norzagaray, Bulacan, Philippines.

Affiant
Driver’s License No: N01-20-020364

SUBSCRIBED AND SWORN to before me this this 14th day of April

2023, hereat Norzagaray, Bulacan, Philippines. Affiant exhibited to me
his above-mentioned ID with picture and signature as competent proof of
his identity.

Public Attorney I/ Swearing Officer

Public Attorney’s Office
(Pursuant to R. A. 9406)