REPUBLIC OF THE PHILIPPINES )

Province of Isabela )S.S.

Municipality of _____________ )

AFFIDAVIT OF VEHICULAR ACCIDENT

I, ________________, of legal age, married and with resident address at ___________, Marikina
City, after having been duly sworn to accordance to law, hereby depose and state:

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

follows:

MAKE/TYPE/SERIES : Toyota/Pick-up/ Hilux 2.4L Conquest.

Engine No. : _____________
Chassis No. : ____________________
Plate No. : __________________

2. That said motor vehicle figured in an accident on _________________, at about

5:30AM while I was driving it along National Highway San Pablo, Isabela.
3. That a goat, without any visible sign of crossing the National Highway, immediately
run towards the road and in front of my vehicle. Causing it to collide with the front
bumper of my vehicle.
4. As I was in a hurry, I did not bother anymore to record the incident.
5. 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 here unto set my hand this ________ day of _____________,
2023 at ______________, Isabela.

_______________
Driver’s license No. __________________

SUBSCRIBED AND SWORN to before me this ____ day of _______________2023, at

_____________, Isabela.

Doc. No. _____;

Page No. _____;
Book No. 30;
Series of 2023.