REPUBLIC OF THE PHILIPPINES }

OLONGAPO CITY } S.S.

AFFIDAVIT OF VEHICULAR ACCIDENT
I, ____________________________________, married, of legal age, a resident of
______________________________________________________________, after being sworn in
accordance with law, hereby depose and say:
That I am the holder of a Non-Professional Drivers License No.
______________________issued by the LTO of ___________________________and valid
until __________________________;
That I am the owner of the subject vehicle more particularly described as
follows:
Make
Year Model
Plate/CS No.
CR No.
OR No.

:
:
:
:
:

________________
________________
________________
________________
________________

That on _____________________________, at around _______________________in the

morning, more or less, I was parking the aforementioned vehicle in the garage;
That
while
________________________
_______________________________________________
______________________________________
___________________________________________________________________________________;
That the ____________________________________________________;
That ____________________________________________________________________;
That the aforementioned situation was an accident beyond my control after
exercising extraordinary care and diligence to safety;
That I execute this AFFIDAVIT to attest to the veracity of the facts stated herein
and for insurance claims purposes.
Done this ____ day of _________________ 2014 at Olongapo City.

______________________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this _____ day of __________, 2014 at
________________, Philippines. Affiant _____________________exhibited to me her Drivers
License I.D. No. __________________; issued on _________________ at _____________________.

Doc. No. ________

Page No. ________
Book No. ________

Series of 2014.