REPUBLIC OF THE PHILIPPINES)

PROVINCE OF OCCIDENTAL MINDORO)S.S

MUNICIPALITY OF SABLAYAN)

AFFIDAVIT OF VEHICULAR ACCIDENT

I, _______________________, (civil status), of legal age, a resident of

______________________________________ after being sworn in
accordance with law, hereby depose and say: That I am the holder of a
Professional Drivers License No. ____________ issued by the LTO of
__________________________ and valid until ______________________;
That I am an the owner of a private car more particularly described as
follows:

Make:
Year Model:
Plate No.
CR No.
OR No.

That on ____________________, at around ____________(time), more or less, I

was driving the aforementioned vehicle on my way to
__________________ from ____________________; That I miscalculated
the depth of a crater on the road because It is filled with water. That the
aforementioned situation was an accident beyond my control after
exercising extraordinary care and diligence to safety; That the same
extraordinary care and diligence was exercised when I took control of the
situation by immediately applying the brakes and preventing a more fatal
vehicular accident. That I execute this AFFIDAVIT to attest to the veracity
of the facts stated herein and for insurance claims purposes.

Done this ___ of ________________ 2018 at Municipality of Sablayan,

Occidental Mindoro. Affiant showing me his Passport/ID/CTC. No.
_______________________ Issued on _______________________________
Issued at _______________________________

Subscribed and sworn to before me this ___________ day of

_____________2018 at Sablayan, Occidental Mindoro.

Doc. No. _______

Page No. _______
Book No. ______
Series of 2018.