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REPUBLIC OF THE OF THE PHILIPPINES)

QUEZON CITY, METRO MANILA) S. S.

AFFIDAVIT OF ACCIDENT
I, , of legal age, Filipino and with business address at, Quezon City, after
having been duly sworn to in accordance with law, do hereby depose and say:

1. That I am a duly licensed and authorized driver with Driver’s License


No. , which is valid until July 6, 2023;

2. That on December 27, 2019, at around 9:00 in the morning, I was


driving a motor vehicle owned and registered in the name of JUAN,
which is more particularly described as follows:

Make: Toyota

3. That on the same day, after I parked the car in front of, and while I was
inside, the Bank of the Philippine Islands, Matalino, Quezon City
Branch, and unknown to me, a motorcycle of unidentified owner and
plate number side-swiped its right hand side from the rear tire area up
until the front bumper;

4. That as a result of the side-swiping, the said vehicle sustained dents,


scratches and/or disalignment particularly its right front fender, right
front door, right rear door, up to the right rear fender;

5. That no one witnessed the incident;

6. That I have executed this affidavit to attest to the truthfulness and


veracity of all the foregoing for all legal intents and legitimate purposes
this may serve especially for all the authorities concerned.

IN WITNESS WHEREOF, I have hereto set my hand and affixed my


signature on this 2nd day of January 2020 in Quezon City, Metro Manila.

SUBSCRIBED AND SWORN to before me on the date and at the place


first above stated.

Doc. No._____;
Page No._____;
Book No._____;
Series of 2020.

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