REPUBLIC OF THE PHILIPPINES)

______________________________) SS

AFFIDAVIT OF ACCIDENT

I, Fritz Limpiada Calvo, Filipino, of legal age and a resident of Unit 304 Villa Alicia II
Condominium, 2659 Zamora Street, Pasay City, after having been duly sworn in accordance
with law, hereby depose and say THAT:

1) I am the owner and driver of vehicle described as follows:

Make/Model : 2018 Mazda 2 RS

Motor No. : P520458801
Serial No. : MM7DL2SAAJW322638
Conduction Sticker No. : RK 6697

2) I am a holder of valid non-professional driver’s license no. N0217020567

issued on July 13, 2017.

3) At around 10:00 am of Saturday, January 6, 2018, while making a turn along

the narrow Protacio Street in Pasay City, I miscalculated the gap between my
car and the rear of a broken down jeepney that was parked along the road, which
resulted to deep scratches and dents on the right side of my car – on the side
view mirror, on the rear door and on the body.

4) This affidavit is executed to establish the above-mentioned facts and to enable

the insured to claim from the insurance company the expenses that may be
incurred in the repair of said vehicle.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 8thth day of January, 2018
at Pasay City, Philippines.

_________________________________
Fritz Limpiada Calvo

SUBCRIBED AND SWORN TO before me this __________________________ in

______________________, Philippines, affiant exhibiting to me his valid proof of identification.

Notary Public

Doc. No. :
Page No. :
Book No. :
Series of 2018