Republic of the Philippines)

Municipality of Ajuy ) S.S.

AFFIDAVIT OF CIRCUMSTANCE

KNOW ALL MEN BY THESE PRESENTS:

I, CHARLES ROEL ELLIE B. FLORA, of legal age, Filipino, and a resident of Brgy. Punta
Buri, Ajuy, Iloilo, after having been sworn in accordance with law, hereby deposes and states the
following:

1. That on September 13, 2022, while traversing at the National Highway of So. Pagsanga-
an,Brgy. Jamul-awon, Concepcion, Iloilo, while riding my Euro 110 CC motorcycle
going to Brgy. Bacjawan Sur Concepcion, Iloilo, I was accidently bumped by a stray dog
by which I incurred injuries in my upper right eye, fractured jaw and scratches in the
different parts of my body;
2. That I am executing this affidavit to attest to the veracity of the foregoing particularly to
prove the accident that occurred and the injuries that I sustained for all legal intents and
purposes this may serve.

IN WITNESS WHEREOF, I have set my hands this 11 th day of November 2022 at Ajuy,
Iloilo, Philippines.

CHARLES ROEL ELLIE B. FLORA

ID NO. _________________________
Affiant

SUBSCRIBED AND SWORN to before me this 11th day of November 2022 at Ajuy,
Iloilo, Philippines. Affiant is personally known to me and was identified by me through
competent evidence of identity as defined in the 2004 Rules on Notarial Practice (A. M. No. 02-
8-13-SC). Affiant exhibited to me his identification card indicated below his name with
photograph and signature appearing thereon at Ajuy, Iloilo, Philippines.

WITNESS MY HAND AND SEAL.

Doc. No. _____;

Page No._____;
Book No._____;
Series of 2022.