Republic of the Philippines)

Mabalacat City, Pampanga) S.S.

AFFIDAVIT OF VEHICULAR ACCIDENT

I, KATHLEEN L. GOZO, of legal age, Filipino citizen, married and residence and
postal address at __________________________________________, after having been duly
sworn in accordance with law, do hereby depose and say:

1. That I am the owner/authorized driver of a motor vehicle particularly described as

follows:

MAKE                   : ENGINE NO.                      :

SERIES                : SERIAL/CHASSIS NO.    :
TYPE OF BODY   : PLATE NO.                        :
YEAR MODEL      : FILE NO.                          :
 COLOR : C.R. NO.                            :

2. That, on 17 February 2015, I went to the Land Bank of the Philippines (LBP) - Clark
Branch;

3. That I parked the motor vehicle in the parking lot allotted for clients of LBP;

4. That, as I was leaving the premises of the said bank, I turned the stick shift of the
said motor vehicle to “reverse” mode;

5. That, while I was backing up, I did not notice that there was an electric post so close
in the rear portion of the motor vehicle;

6. That, I accidentally hit the electric post from the rear portion of the motor vehicle;

7. That, as a result, the motor vehicle sustained damage to _______________________;

8. That the abovementioned motor vehicle is insured under ______________________;

9. That I am executing this affidavit to claim from the said insurance the damages
sustained by the motor vehicle;

10. That I am executing this affidavit to attest to the truth of the foregoing statements
and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 18 th day of

February at Mabalacat City, Pampanga, Philippines.

KATHLEEN L. GOZO
Affiant
          
 SUBSCRIBED AND SWORN to before me this ______________________at
Mabalacat City, Pampanga, the affiant having been exhibited to me her
_________________________________________________, personally signed the foregoing
instrument before me and acknowledged to me that he freely and voluntarily executed the
same.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2015.