CIUKGIISIR ARICD

Rs.20
.20
UTY EXEM

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INDIA NON JUDIC
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TiRT CHHATTISGARH 08AA 614818
AFFIDAVITI
Ankta Som D/o Ashoka Som reslding at Clvil LInes, Garlyaband PO do hereby solemnly
affirm and declare on oath as under

1. That I am the registered owner of vehicle/car No. CG 04 LS 9966.

2. That this vehicle is insured with United India Insurance Co.
Ltd. Vide Policy No.
22300031210160059728 form 08.02.2021 to 07.02.2022.
That this vehicle has met with an accident on 12.02.2021 at about 9.00 PM Near
OTARA Gariyaband.
That at the time of accident Ankita Som D/o Ashoka Som was
/LN.AWasmi and his driving Llcense No is A/17082/R.
Driving this vehicle/car
3. That there was no third party loss involved In this
accldent and no one has injured in
D5TLGARANDca his accident as such no FIR was lodged with the Police.
2 EG MC CO.a0 3/ThatI Hold myself responsible for any claim at any later
DATE-191 stage, if filed by any third party
f o r third party loss of injuries pertaining to this
any
accidknt
CHHAace Deobhog (Garya
Pate -29-09-2021.
DEPONENT

erification
I, the above named deponent further declare that the contents mentioned above are
frue and correct to the best of my knowledge and belief and nothing has been kept concealed
therein.

DEPONENT
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pNeeyad o
Notery Advecute,