REPUBLIC OF THE PHILIPPINES }

ZAMBOANGA CITY } S.S.

AFFIDAVIT OF VEHICULAR ACCIDENT

I, RIMAISA MASDAL ISAHAC, of legal age, married and with residence

address at Villa Teresa Subdivision, Barangay Divisoria, Zamboanga City, after having
been duly sworn to according to law, hereby depose and state:

1. That I am the registered owner of a motor vehicle which is specifically described

as follows:

MODEL : MITSUBISHI MIRAGE G4 GLX 1

MOTOR NO. : 3A92UBA6718
CHASSIS NO. : MMBSTA13AEH003172
COLOR : RED
PLATE NO. : AAF 6757

2. That said motor vehicle figured in an accident on January 05, 2019, at around
5:00 p.m. in the afternoon, when I visited my brother, Yusop B. Masdal, and his
wife, Mrs. Evelyn C. Masdal, at their house at Lustre Street, Barangay Sta.
Catalina. The accident occurred while I was driving my car and upon entering my
brother’s house through their gate. I was in a hurry at that time;

3. That when I was about to enter the above-cited gate, the left front door of the car
hit a portion of the gate causing it to be dented heavily, including damage to the
left side mirror;

4. That when I backed the car on reverse, the right rear door hit a portion of the
gate that it had scrapes and gashes as well as small dents. In this particular
maneuver, the rear bumper of my car also hit a portion of the gate that it incurred
scrapes and gashes. Then I drove forward again and then the front bumper had
been dented and scraped as well;

5. That the above-cited occurrences happened in just one afternoon wherein

afterwards, I have observed that the damage to the car was the following:

a) Dents/Scrapes at Front Bumper Right Portion

b) Dents/Scrapes at Front Door Left/Right
c) Dents/Scrapes at Rear Door Left/Right
d) Scrapes at Rear Bumper
e) Scrapes at Rear Quarter Panel Right

6. That the aforementioned situation was an accident beyond my control after

exercising extraordinary care and diligence to safety; and

7. That I am executing this affidavit in order to attest to the truth of the foregoing
circumstances and for the purpose of reporting the matter to my insurance office
for insurance claims.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

February, 2019 at the City of Zamboanga, Philippines.

RIMAISA MASDAL ISAHAC

Affiant
 SUBSCRIBED AND SWORN to before me this ____ day of February, 2019,
affiant exhibited a competent proof of her Identity with I.D. No. LTO No. JO4-14-
001906.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2019

ATTY. LOVELL C. ABAD

Notary Public
Doc No. ____ Notarial Comm. No. 26-2018 until
December 31, 2019
Page No. ___ PTR No. 1623721 dated January 5,
2018
Book No. ____ Lifetime IBP No. 703682 dated June
5, 2007
Series of 2019 IBP Roll No. 48879/ MCLE No. V-
0002021/4-15-16 to 4-14-19
2nd Floor, JA Building, Governor Ramos
Avenue
Sta. Maria, Zamboanga City/0916-
477-5551