REPUBLIC OF THE PHILIPPINES) S.S.

CITY OF SAN PABLO)

AFFIDAVIT OF ACCIDENT

I, WENDY GUTIERREZ TEOPE, Married, Filipino, of legal age, and with

residence at #047 Brgy. San Pedro, San Pablo City Laguna, after having been duly
sworn to in accordance with law, hereby depose and say that:

1. I am the owner and authorized driver of one motor vehicle which is particularly
described as follows:
MAKE AND MODEL: Hyundai Accent Sedan CRDI
MV FILE NO.: 1336-00000477010
CONDUCTION STICKER NO.: MV 4506

2. On 29 July 2019 at around four o’çlock in the morning, I was on the way to
Calamba City and was driving along the Provincial Road of Brgy. Imok, Calauan,
Laguna when an animal which appears to be a cat suddenly crossed the road.

3. As the animal was fast, I did not have the chance to evade it or apply my brakes
which led to my hitting of the animal and running over it.

4. Immediately thereafter I swerved and stopped on the side of the road.

5. When I checked the vehicle, I have observed that the front bumper was cracked,
a part thereof is hanging, a part was missing, and it was severely scratched.

6. The accident happened so fast and went beyond my control.

7. I am executing this affidavit to attest to the truth of the foregoing statement.

WENDY GUTIERREZ TEOPE

Affiant

SUBSCRIBED AND SWORN to before me this 30 th day of July 2019 at San

Pablo City, Affiant exhibiting to me her Bureau of Fire Protection ID numbered G29045
valid until 27 August 2020 and issued at Quezon City on 12 December 2017.