REPUBLIC OF THE PHILIPPINES)

CITY OF DAGUPAN) S.S.

AFFIDAVIT OF ACCIDENT

I, _____________, of legal age, Filipino, with residence address at ___________,

after having been duly sworn to in accordance with law hereby depose and state the
following: THAT-

1. I am the authorized Driver of a motor vehicle which is more particularly

described as follows:
Year Model :
Make/Type :
Plate No./Cond. Sticker No:
Engine No. :
MV File No. :
CR No. :

2. I am a holder of driver's license No. issued by the Land Transportation Office and
which will expire on 2018-09-09;
3. The above described vehicle is owned/registered in the name of and which is
insured with Commonwealth Insurance Company:
4. It figured in accident at about ______;
5. Place of accident:____;
6. It was bumped by; ____________;
7. Name of Third Party Driver/address: ______________________;
8. Name of registered owner/address: ___________________
9. That (describe the incident)

IN WITNESS WHEREOF, I am executing this affidavit to attest to the truth of the

foregoing facts herein contained and for the purpose of establishing the fact that my
driven vehicle was hit and bumped at its rear portion, thereby incurring broken tail light,
scratched and disaligned rear bumper, and scratched and dented rear sidings.

____________
Driver/Affiant

SUBCRIBED AND SWORN TO BEFORE ME, this____ day of _____ at

Dagupan City, affiant exhibited to me his/her competent proof of identity:
Driver's License No. with expiry date on September 9, 2018.

Doc. No.___;
Page No.___;
Book No.___;
Series of 20___.