Republic of the Philippines

City of Malabon

)
) S.S.
AFFIDAVIT OF ACCIDENT

I, CHONA A. VELASCO, of legal age, Filipino citizen, and a resident of 30

Bronze Street, Tugatog, Malabon City, under oath, hereby depose and state
that:
1. That I am the registered owner of a motor vehicle known as Kia
Picanto, color Signal Red, model 2014 and with plate number AAI 5697.
(Copy of the certificate of registration, official receipt and drivers license
are hereto attached as Annexes A, B and C, respectively.)
2. That sometime on the 4th of June 2014, while the aforementioned
vehicle was parked outside of my house, an unidentified motor vehicle
rear-ended it.
3. That due to such collision, my vehicle suffered a dent on its trunk and
rear bumper area.
4. That I am executing this affidavit to attest to the foregoing and for
whatever legal purpose it may serve.
AFFIANT FURTHER SAYETH NAUGHT.

CHONA A. VELASCO
SUBSCRIBED AND SWORN TO before me this ___ day of June 2015 in
Malabon City after affiant exhibited to me her Drivers License with
Number _______ valid until ______
NOTARY PUBLIC

Doc. No._____;
Page No._____;
Book No._____;
Series of 2015.