Republic of the Philippines)

Province of Negros Oriental)s.s.

Municipality of Sibulan.…)

AFFIDAVIT ON AN ACCIDENT

I, ELISA V. CALA, of legal age, Filipino, and a resident of Northville, Boloc-

boloc, Sibulan, Negros Oriental, after having been sworn to in accordance with law, do
hereby depose and state that:

I am the registered owner of one (1) motor vehicle, which is more particularly
described as follows:

MAKE: TOYOTA ENGINE NO.: 1KRA423874

BODY TYPE: HATCHBACK C.R. NO.: 298954375
CHASSIS NO.: MHKA4DF5FHJ008197 YEAR MODEL: 2018
SERIES: WIGO 1.0 G AT MV FILE NO.: 0701-
00000613555

That on December 19, 2022, I was backing the above-mentioned vehicle in our
house in Northville, Boloc-boloc, Sibulan, Negros Oriental when the rear portion/bumper
of the said vehicle accidemtay hit a post of our house;

After the incident, I noticed that the rear portion/bumper vehicle was damaged,
scratched, with detachments.

That this affidavit is executed freely and voluntarily to attest the veracity and
truthfulness of my statements herein.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

___________________ in Sibulan, Negros Oriental, Philippines.

ELISA V. CALA
Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, on this

___________________ for the Municipality of Sibulan and the Province of Negros
Oriental, Philippines, the above-named affiant, exhibited his
______________No.___________________, and WHO SIGNED IN MY PRESENCE
the foregoing document (AFFIDAVIT ON AN ACCIDENT), and who avows under
PENALTY OF LAW to the whole truth of the contents of the same.

Doc No. ___;

Page No.___;
Book No. ___;

Series of 2022.