REPUBLIC OF THE PHILIPPINES)

CITY OF _______________ ) S.S.

AFFIDAVIT OF ACCIDENT

I, ___Teresa Marielle Coloma Redillas_______________, of legal age, Filipino, with residence

address at _____Peakaboo Townhouse Brgy. Tuktukan Guiguinto, Bulacan_____; after having
been duly sworn to in accordance with law hereby depose and state the following: THAT-

1. I am the authorized Driver of a motor vehicle which is more particularly described as

follows:
Year Model : __2021__
Make/Type : ___Toyota Utility Vehicle___
Plate No./Cond. Sticker No: __NGL7292__
Motor No. : ______1GD0948789______
Serial No. : _PA2AA8EM3M0089452__

2. I am a holder of driver's license No.____C07-21-009160____________ issued by

_____C07 /_Guiguinto LTO_____, and which will expire on ___2026/05/14_________;
3. The above described vehicle is owned /registered in the name of
_________Hector_P._Villamero___________________ and which is insured with
Commonwealth Insurance Company under policy number ____CV1534123______;
4. It figured in accident on (time/date/month/year) _12:30AM_July_10,_2023______;
5. Place of accident: _Brgy. Tikay City Of Malolos Bulacan_______________________;
6. It was bumped by; ____CR-V________ with Engine No.__K24Z98503980___;
7. Name of Third Party Driver / address: ____Palwinder Singh______ /
_______________17 Bayani St. Brgy. Santol, Quezon City__________;
8. Name of Registered Owner / address: ____Hakam Singh________
/__55B_PAG_ASA_San Jose -_Kalookan City NCR, Third District National Capital Region.

Please state / explain how the accident happened:

___________________________________
As I was on my way home I stopped at a red light at Brgy Tikay Malolos City Bulacan. Then all
of a sudden I felt jerky motion while inside my vehicle. That's how I know I was rear ended by
Palwinder Signh. That resulted to the damages on my Toyota Innova.

IN WITNESS WHEREOF, I am executing this affidavit to attest to the truth of the

foregoing facts herein contained and for the purpose of establishing the fact that my driven
vehicle was hit and bumped at its ______________________________________.

Teresa Marielle C. Redillas

Signature over Printed name
Driver/Affiant

SUBCRIBED AND SWORN TO BEFORE ME, this ___ day of _____________, 20___
at ____________________, affiant exhibited to me his/her competent proof of identity:
SSS No. ___________________________ / TIN No. ____________________________
Driver's License No. ____________________with expiry date on: __________________

Notary Public
Doc. No.___;
Page No.___;
Book No.___;
Series of 201__