REPUBLIC OF THE PHILIPPINES)

CITY OF NAGA)
X-----------------------------------X

AFFIDAVIT OF ACCIDENT

I, FREDERICK R. EBOA, Filipino, of legal age, with residence address at St. James
Homes, Phase 2, Wyoming Street, Concepcion Grande, Naga City, after having been duly sworn
to in accordance with law, hereby, depose and say that:

I am the authorized driver of one motor vehicle which is particularly described as

follows:

MAKE AND MODEL : 2016 Toyota Wigo 1.0 G M/T

CHASSIS NUMBER : MHKA4DE3FGJ009079

MOTOR NUMBER : 1KRA317298

PLATE NUMBER : ACR 4038

On December 1, 2016, between 9:00 11:30 am, while I was parked within the premises
of Naga College Foundation, in front of the M.T.Villanueva Building and under the shade of a
palm tree, a leaf sheath of said tree fell down straight to the roof of the above described motor
vehicle. As a result, a portion of the roof of the vehicle was damaged.

On another incident, December 19, 2016 at around 9:00 pm, while I was leaving the
parking area and driving the above described vehicle in a reverse gear, in front of Red Platter
Restaurant along Magsaysay Avenue, Naga City, I did not noticed the steel post erected which
was about one meter in height. As a result, I suddenly bumped said steel post which caused a
dent on the rear bumper and slightly broke the tail light of said motor vehicle.

I am executing this affidavit to attest to the truth of the foregoing statement and in
support of my claims for the repair of the vehicle damages from the insurance company.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of _______ 2016
at ______________, Philippines.

FREDERICK R. EBOA
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ______ 2016 in

______________, Philippines, affiant exhibiting to me his/her competent evidence of identity by
way of PRC identification card with registration no.0045189 issued at PRC Legaspi City
on March 21, 2016.

Doc No. : _____ Notary Public

Page No.: ______

Book No.: ______
Series of