Republic of the Philippines }

________________ }s.s

AFFIDAVIT OF VEHICULAR ACCIDENT

I, ________________________, of legal age, single and with residence address at

____________________________, after having been duly sworn to according to
law, hereby depose and state:

1. That I am the registered owner of a motor vehicle which is specifically

described as follows:

MODEL :
MOTOR NO. :
CHASSIS NO. :
COLOR : Red
PLATE NO. : __________

2. That said motor vehicle figured acts of vandalism on

___________________. At about ______________, I parked my vehicle in
___________________ where I spent some time in buying groceries.
Shortly thereafter, I came back and found my vehicle with several scratches
or had been vandalized. In the same place, I have noticed that there were
street children playing sharp objects few meters away from my vehicle
before I proceeded with my errand.
 3. As the incident happened late at night, I did not bother anymore to summon
a policeman to record the accident;

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 ___ day of

__________, 201____ at the City of __________________.

____________________
Affiant

SUBSCRIBED AND SWORN to before me this __ day of ___________ 201____,

affiant exhibited a competent proof of their Identity:

Govt. Issued I.D. Valid Until

_______________________ ________________

Notary Public Doc. No. __________;

Page No. __________;
Book No. __________;
Series of 201____.