REPUBLIC OF THE PHILIPPINES)

CITY OF KAPA……)S.S.
x--------------------------------------------x

AFFIDAVIT OF ACCIDENT
I, XXXXXXXXXXXXXX, of legal age, Filipino, single and resident
of Blk. 0 Lot 0, Pag- Asa Subd., Phase 69, Brgy. Mabuhay, Kapa City, after
being sworn in accordance with law, hereby depose and say:

1. That I am the designated driver of a utility vehicle identified as

ABC 123 registered under the name of CHARMOS GINAMOS;

2. That the said vehicle committed an accident on 3 May 2019 at

around 8:00 in the morning while traversing the National Highway going to
the Municipality of Rigen, Province of Almamico;

3. That a ten-wheeler truck was also traversing the road in the

opposite lane on a fast speed. As the truck was fast approaching on my
opposite side, a stone was immediately hit the vehicle on its driver side
causing me to stop for a while to check if there is a damage to the vehicle;

4. That unfortunately, I was not able to stop the driver of the truck
or get the plate number of the said truck. The accident happened so fast and
it went beyond my control;

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

foregoing facts and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereto affixed my hand this 8th

day of May 2019 at Kapa City.

XXXXXXXXXXXXXXXXX
Affiant
SUBSCRIBED AND SWORN to before me, this 8th day of
May 2019 at Kapa City; affiant exhibited his ID bearing his photograph and
signature as competent evidence of his identity.