A F F I D A V I T

OF VEHICULAR ACCIDENT

I, DASMIN ANNE B. DEPACAQUIBO, Filipino, of legal age and a resident of 86

CATTLEYA ST. PERMALINE HOMES, NANGKA, MARIKINA CITY. After being duly
shown to, hereby depose and state as follows:

1. That I am the authorized driver of one (1) motor vehicle registered under the name of
DASMIN ANNE B. DEPACAQUIBO, describe to wit:

Make & Type : MG ZS ALPHA SUV

Year : 2022
Engine No. : 15S4C8FGMB280230
Chassis No. : LSJW74U94NZ085822
Plate No. : NGK1003

2. That on the 10th day of AUGUST 2023, around 9am in the morning at 81 Ilang Ilang St.
Pingkian III, Brgy. Pasong Tamo, Quezon City, the car was unattended and then
suddenly it was accidentally hit by a jeepney driver. Causing the damages to the RIGHT
TAIL LIGHT, RIGHT REAR BUMPER RETAINER, RIGHT REAR FOG LIGHT,
RIGHT REAR LOWER BUMPER, RIGHT REAR TOW HOOK COVER, and
RIGHT REAR MAG WHEEL.
I am executing this affidavit to attest to the truthfulness of the above facts in support of the
insurance claim for the repair of the subject motor vehicle and for any and legal intents.
IN WITNESS WHEREOF, I have affixed my signature below this 10th day of August, 2023in
Quezon City.

DASMIN ANNE B. DEPACAQUIBO

Affiant

SUBSCRIBED AND SWORN TO before me this ______ day of ______ 2023, in

_______________, Philippines, Affiant personally appeared and showed ti me his/her competent
evidence identity in Driver’s License No.: NO 1-22-004343

____________________________________
NOTARY PUBLIC

Doc. No. ______ Until December 31, 20_______

Page No. ______ P.T.R. No. _________________
Book No. ______
Series of 2023