REPUBLIC OF THE PHILIPPINES)

CITY OF ______________________)

AFFIDAVIT OF ACCIDENT

I, Christ N. Bartolome, Filipino, of legal age, with residence address at Blk 3 San Manuel,
Tarlac City, after having been duly sworn to in accordance with law, hereby, depose and
say that I am the authorized driver of one motor vehicle which is particularly described as
follows:

MAKE AND MODEL : Toyota Wigo 1.0.GAT

SERIAL NUMBER : 0301-00001285212

MOTOR NUMBER : 1KRA553816

PLATE NUMBER : CAV5925

On August 31, 2023 at around four o’clock in the afternoon, I was driving along San Roque
Tarlac City going northbound. In the same lane, an SUV was also traversing the road in
front of me on a fast speed then suddenly stops causing me to crash the said SUV and
damage the front part of my car. Unfortunately, I was not able to stop the driver of the SUV
nor get the plate number of the car. The accident happened so fast and went beyond my
control. I am executing this affidavit to attest to the truth of the foregoing statement and in
support of my claims for reimbursement from the insurance company.

_____________________

Affiant

SUBSCRIBED AND SWORN to before me this _______day of _____________,20___

at______________, Affiant exhibiting to me his Valid Identification
_____________________________ issued at _____________ on
_____________________.

NOTARY PUBLIC

Doc. No. _______

Page No. _______
Book No._______
Series of _______