REPUBLIC OF THE PHILIPPINES )

CITY DASMARINAS. . . . . . . ) S.S.

PROVINCE OF CAVITE

A F F I D A V I T OF ACCIDENT

I, ELAINE E. HERBERT, of legal age, single, with residence and postal

address at Fuentes St., Brgy. 3, Green Valley Nasipit, Agusan Del Norte, after being
duly sworn to in accordance with law, depose and state: That - -

1. I am the registered owner of a motor vehicle particularly described as

follows:

UNIT: FORD EVEREST 2.2L 4X2 Serial No.: MNCAXXMAWAFM26051

AMBIENTE AT
Model: 2016 Motor No.: P4AT2125448
Type: WAGON Plate No.:
File:

2. Unfortunately, on 21st of June 2017, at around 4:00 a.m, I discovered that

while the above vehicle was parked at my sisters house at Gawaran St.,
Digman, Bacoor, Cavite, it was sideswipe by an unknown vehicle;

3. The incident was out of my knowledge because I was sleeping at my

sisters house and just discovered it in the morning after.

4. On account of said accident, the front side of the vehicle was damage;

5. Further, I hereby declare under oath that I exerted sincere efforts to

ascertain who and what caused the above-mentioned damages but to no
avail;

6. I am executing this affidavit to attest to the truth and veracity if the

foregoing statements and for whatever legal purpose the same may serve;

IN WITNESS WHEREOF, I have hereunto affixed my signature this 23rd day

of August 2017 in Dasmarias City, Cavite.

ELAINE E. HERBERT
Affiant

SUBSCRIBED AND SWORN to before me this 23rd day of August 2017

affiant exhibiting to me her SSS#33-0007947-9.

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Series of 2017