AFFIDAVIT OF ACCIDENT

I, GILBERT U. PEREZ, of legal age, Filipino, married, and a resident of 0426 Unit D, L Residences, Purok 1
Street, Purok 1, Barangay Tikay, Malolos, Bulakan, after having been duly sworn to in accordance with
law, do hereby deposes and states:

1. That on the 18th of October, 2020, I parked my company vehicle, with Conduction
Number C1N531 and License Plate Number NBE2168, at Puregold, Guiguinto, at
around 6;00 p.m.;

2. That on said date, after having done my groceries, I returned to said vehicle by 7;00
p.m. and immediately noticed that the passenger side side mirror was completely
damaged, and paint damage on right front fender, apparently side swiped by
another vehicle;

3. That undersigned voluntarily executes this Affidavit for the purpose of insurance
claims and further, to attest the truth of all foregoing and for other legal intents and
purposes it may serve.

IN WITNESS WHEREOF, I have hereto affixed my signature this 19th of October 2020, heare at Malolos,
Bulacan.

GILBERT U. PEREZ

Affiant
SUBSCRIBED AND SWORN to before me this 19th day of October, 2020, at Malolos City, Bulacan, affiant
exhibiting to me his Drivers License No. _N02-08-020787, and known to me and to me known
personally to be the same person who executed the foregoing Affidavit.

Doc. No. ___; NOTARY PUBLIC

Page No. ___;

Book No. ___;

Series of 2020.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . . ) S.S.