Republic of the Philippines }

City of _____________ } s. s.
x------------------------------------x

AFFIDAVIT OF ACCIDENT

I, _____________, Filipino, of legal age, single, and a resident ____________________, Philippines,

after being sworn to in accordance with law, depose and state THAT:

1. I am a duly licensed driver with Driver’s License No. _________________ covered by LTO O.R.
No. ____________________, which is valid until _____________________;

2. I am duly authorized to use and drive the car owned and registered in the name of
______________________, which is more particularly described as follows:

Make
Series
Engine No.
Chassis No.
Body Type
Plate No.
Year Model
MV File No.

3. Sometime on _________, at around nine __________ I drove above-described motor vehicle

to _________________________________;

4. While I was trying to park said vehicle, I accidentally slipped and slammed the accelerator
pedal, and said vehicle suddenly hit a pile of neem tree trunks and branches, causing
damage to the right side portion of said vehicle. Out of panic, and without noticing that
some trunks and branches got stuck to the lower portion of the bumper, I immediately
reversed the vehicle causing further damage thereto;

5. I am executing this Affidavit to attest to the truth of the foregoing and in support of the
claim against the insurer for the repair of the damage sustained by said vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this ______________________ at

___________________________, Philippines.

_________________________
Affiant

SUBSCRIBED AND SWORN TO before me this __________________ at

________________________________, Philippines. Affiant exhibited to me her LTO License No.
___________________, valid until ________________.

WITNESS MY HAND AND SEAL.

AFFIDAVIT OF ACCIDENT Page 1 of 1