REPUBLIC OF THE PHILIPPINES )

MANILA CITY ) S.S.

AFFIDAVIT OF SELF ACCIDENT

I, Radz Cambotok Amin, Married, and of legal age, a resident 953 Padilla st., San Miguel,
Manila, after being sworn in accordance with law, do hereby depose and say:

1. That I am the holder of a Professional Driver’s License No. N04-95-327362 issued by

the Land Transportation Office, and valid until 06/29/2023;

2. That I am an employee of AVIA Management Group Inc. and was assigned a vehicle
described as follows:
Make/Type : Toyota HIACE GL GRANDIA
Year/Model : 2018
Conduction Sticker No. : C-A60A
Engine No. : 1KD2797576
3. That sometime on July 6, 2018 at around 6:30 am, I was maneuvering the
aforementioned vehicle to park at the provided parking slot No. 138 to Avia
Management Group Inc. located at the 3rd Floor parking Area of ANTEL SEAVIEW
TOWERS.

4. That I accidentally hit a pillar of the building while maneuvering for parking, due to
poor lighting in the said parking area which damaged the rear portion of the vehicle
which includes tail light, tail gate, rear windshields and caused dents on the rear bumper
and tail gate of the aforesaid vehicle. Attached herein as Annexes “A” to “E” are the
pictures of the damage to the vehicle.

5. That the aforementioned incident was an accident beyond my control after exercising
extraordinary care and diligence to safety; that the same extraordinary care and
diligence was exercised when I took control of the situation by immediately applying
brakes and preventing further damage to the aforesaid vehicle.

6. That I execute this Affidavit to attest to the truthfulness and veracity of the facts stated
herein and for insurance claim purposes and other legal purposes it will serve.
Done this ________________ at Manila City.

Radz Cambotok Amin

Affiant

License No. N04-95-327362

Issued on: ______________
Issued at: _______________

Subscribe and sworn to before me this ___________________of July at Pasay City,

Philippines.
Doc No._______
Page No. ______
Book No.______
Series of 2018.