Republic of the Philippines…)

City of Pasig )S.S

x…………………………….x

AFFIDAVIT OF ACCIDENT

I-------------, of legal age and currently residing at

-----------------------------------------------------------after having sworn to an oath and depose
that;

1. That I am the registered owner of a motorcycle which is specifically

described as follows:

MODEL
PLATE NO:
COLOR:

2. That said motorcycle figured in an accident on 11:30 am of February 21,

2019 along Congressional RD, Quezon City while I was traversing the congressional
road on way right then and there I felt dizzy, and suddenly out of control that made
sideswipe to the park un attended motorcycle on the right side of the lane. I fell from
motorcycle thus resulted to sustained injuries and broken bone both arms and legs.

3. I was brought Quezon City General Hospital to receive treatment and was
advised to take rest from the February 21, 2009 until March 14, 2019 to recover and
heal completely.

That I executed this counter-affidavit to attest to the truth of the foregoing of

reporting this matter to my office to support my application of leave of absence .

IN WITNESS WHEREOF, I hereto set my hand this day of _________ 2019 at

the city of Pasig.

Affiant

SUBSCRIBE AND SWORN to before me this ______ day of March 2019 at

Pasig City and further certify that I personally examined the affiant and that I am
satisfied that he had voluntarily executed and understood the foregoing affidavit.

ADMINISTERING OFFICER