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REPUBLIC OF THE PHILIPPINES )

CITY OF LAOAG ) S.S.

AFFIDAVIT OF ACCIDENT

I, , of legal age, single, Filipino citizen and a resident of Brgy.


Philippines, after having been duly sworn to in accordance with law, do
hereby voluntarily depose and state: That-----

1. I am the registered owner of the 2016 Toyota Innova 2.8G DSL , more
particularly described as follows:

Plate No. Frame No.:


Cond. Sticker: Engine No.:
Color: Motor No.
SERIAL No.

2. On January 10, 2017 at about 7 o’clock in the evening, while I was


driving on my way home, along the Barangay Road, a stray dog
suddenly crossed in front of the aforementioned car that I was driving;

3. I tried to maneuvered to the right side of the road to avoid hitting the
said dog. Since the barangay road is too narrow, I accidentally hit the
tree beside the barangay road;

4. As a result, the car I was driving incurred damages and scratches on


its front side, as well as its hood, which necessitates repair, painting,
cleaning, detailing, removal and installation of some parts of the said
vehicle;

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


facts and for all legal intents and purposes;

IN WITNESS WHEREOF, I have hereunto set my hand this


________________ at Laoag City, Philippines.

IBP ID NO. Roll


Issued by the Integrated Bar of the Philippines

SUBSCRIBED AND SWORN to before me this ______________ at Laoag


City, Philippines, affiant exhibiting to me his identification card indicated
below his name and signature as competent proof of his identity.

Doc. No.
Page No.
Book
Series of 201

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