REPUBLIC OF THE PHILIPPINES)

MATAASNAKAHOY, BATANGAS) S.S.

AFFIDAVIT OF SELF ACCIDENT

I, TENBER CAMBA GROTA of legal age. Filipino, single, and a resident of Langka St.,
Lalud, City of Calapan (Capital) Oriental Mindoro, Phililppines, after being sworn in accordance
with law, do hereby depose and say:

1. That I am the holder of a Professional Driver’s License No. D05-14-001051

issued by the Land Transportation Office, and valid until 2032/09/10;

2. That I am the driver of a vehicle described as follows:

Make : Toyota
Year/Model : 2022
Plate No. : VAB3647
Engine No. : 2NRX906674
3. That sometime on June 7, 2022, I was driving and about to turn right;

4. As I was approaching the kerb, a boulder scraped against the right lower side of my
car leaving a scuff on the plastic panel;

5. That the plastic screws within also got dislodged exposing the inner section of the
panel;

6. That I execute this Affidavit to attest to the truthfulness and veracity of the facts
stated herein and for insurance claim purposes and other legal purposes it will serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ______ day of June 2023
at Mataasnakahoy, Batangas, Philippines.

TENBER CAMBA GROTA

Affiant

SUBSCRIBED AND SWORN to before me this _______ day of June, 2023 in

Mataasnakahoy, Batangas. Affiant exhibited to his competent evidence of identity as Driver’s
License - D05-14-001051

Notary Public

Doc. No____;
Page No. ___;
Book No. ___;
Series of 2023.