Republic of the Philippines )

City of Tagum Davao del Norte )

AFFIDAVIT OF ACCIDENT

I, ____________, of legal age, Filipino, and a resident of

____________________. Kingking, Pantukan, Davao de Oro, after having
duly sworn to in accordance with law, hereby depose and state that:

1. I am the driver of a Nissan Pick-up Navarra 2.5L 4x4 covered by

Certificate of Registration No. __________ registered in the name of
the Provincial Government of Compostela Valley, particularly described
as:

MV FILE : ____________
ENGINE NO : ____________
CHASSIS NO. : ___________

2. On or about August 8, 2022 at around 12:30pm, I was driving the said

vehicle from Pantukan, Davao de Oro going to Nabunturan, Davao de
Oro;

3. Upon reaching Brgy. San Roque, Nabunturan, Davao de Oro around

1:45pm, the said vehicle was hit by a flying stone that came from the
wheel of an undetermined type of truck running in the opposite
direction of the road;

4. As a result, the said Nissan Pick-up Navarra incurred damage on its

front wind shield;

5. I am executing this affidavit to attest to the truth of the foregoing

statements and to apply for insurance coverage for the repair,
replacement and reinstallation of the parts that was damaged and for
such other legal purpose this may serve best.

IN WITNESS WHEREOF, I have signed this affidavit this ___________

in Tagum City, Davao del Norte.

_________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _____________ in

Tagum City, Davao del Norte, affiant is personally known to me.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2021.