7/16/2019 Affidavit of Accident (Self Accident)

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REPUBLIC OF THE PHILIPPINES)CITY OF ______________________) AFFIDAVIT OF ACCIDENT

I , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , F i l i p i n o , o f l e g a l a g e , w i t

h e ! i " e n # e a""e! ! at ___________________________________________ ,af te ha$ing %een "&l'!won to in a##o"an#e with law, hee%', "epo!e an" !a' that(I

a the a&thoi*e" "i$e of one oto $ehi#le whi#h i! pati#&lal' "e!#i%e"a!follow!(+-E N. +O.EL (SERIL NU+BER (+OTOR NU+BER (PLTE NU+BER (On /an&a' 01, 0234 at ao&n" fo& o5#lo#6 in the aftenoon, I wa! "i$ing alongipot Roa" at

Paa7a8&e Cit' going !o&th%o&n"9 In the !ae lane, a ten:wheele t&#6 wa! al!o ta$e!ing the

oa" on ' ight !i"e on a fa!t !pee"9 ! the t&#6 wa! $e' fa!t, I"i" not ie"iatel' noti#e thatit !i"e!wipe" the ight !i"e potion of ' "i$en $ehi#le9Unfo t& nat e l', I wa ! not a%le to

!top the "i$e of the t&#6 no get the plate n&%e of the t&#69 The a##i"ent

happene" !o fa!t an" went %e'on" ' #ontol9I a e;e#&ting thi! affi"a$it to atte!t to the t&th

of the foegoing !tateent an"in !&ppot of ' #lai! fo ei%&!eent fo the in!&an#e#opan'9 _____________________ ffiantSUBSCRIBE. N. S<ORN to %efoe e thi!

 _______"a' of _____________,02___ at ________________, ffiant e;hi%iting to e hi!=he

Re!i"en#e Cetifi#ate No9= >ali" I"entifi#ation _____________________________ i!!&e" at _____________ on _____________________9 NOTRY PUBLIC.o#9 No9 _______ Page No9

 _______ Boo6 No9_______ Seie! of _______