REPUBLIC OF THE PHILIPPINES )

CITY OF PASAY ) S.S.

AFFIDAVIT OF ACCIDENT

I, IRIS C. CASTILLON, Filipino, of legal age, married/single, and a resident of Lot 1 Blk 24,
Parksville Subdivision, Alapan II-A, Imus City, Cavite, Philippines, after being sworn to
accordance with the law, hereby depose and state:

1. That I’m the holder of a Profession Driver’s License with NO3-05-008571, valid until
2033/04/07;
2. That on December 27, 2023 at around 2:48AM, I was driving at National Highway-
Candelaria Quezon Province first incident happened. Driver’s Side-Bump by Delivery
Van.
Damages: Headlight
Hood
Side Mirror
Driver’s Door
Passenger’s Door (Back of Driver’s Side)
3. That on January 8, 2024 at around 4:43PM, I was driving at National Highway-
Candelaria Quezon Province second incident happened. Tail Light Passenger’s Side-
Bump by a jeep
Damages: Bumper Passenger’s Side
4. That the abovementioned vehicle is more particularly describes as follows:
Year Model: 2024
Engine No: K10CNC2379196
Chassis No: MA3FL61S4RA461923
Color: Granite Grey
CS NO: G4V975
5. Copy of the Picture of Damages attached and marked as Annex “B”;
6. That I am executing this Affidavit to attest the truth of the foregoing facts and in support
of the claim from the insurer for the repair of the damage caused to the said vehicle and
for whatever legal purposes or worth it may serve best.

IN WITNESS WHEREOF, I hereunto affix my signature this 11th day of January 2024 at Pasay City.

IRIS C. CASTILLON
Affiant
th
SUBSCRIBED AND SWORN to before me this 11 of January 2024 at Pasay City, affiant
exhibiting to me his Driver’s License with License No. NO3.-05-0085741.
 NOTARY PUBLIC

Doc. No. ___;

Page No.____;
Book No.____;
Series of 2024.