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Republic of the Philippines )

Province of La Union ) s.s.


Municipality of Naguilian )

AFFIDAVIT OF INCIDENT

I, JANET R. ESTEPA, of legal age, single, Filipino citizen and a resident


of Gusing Norte, Naguilian, La Union, after having been sworn to on oath in
accordance to law, hereby depose and state that:

1. I am the authorized driver of a motor vehicle, particularly a Mitsubishi


Lancer with plate number DNI98;

2. However, on 12 June 2018, said motor vehicle incurred damages on


the left side of its bumper when I accidentally ran over a boulder;

3. I am executing this affidavit to attest to the truth of the foregoing


facts particularly for insurance claims to defray the expenses incurred
for the repair of the said motor vehicle;

4. Further, I am executing this affidavit in good faith and in accordance


to law.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 7th


day of July 2018 in Naguilian, La Union, Philippines.

JANET R. ESTEPA
Affiant
Driver’s License No. A15-01-003474

SUBSCRIBED AND SWORN TO BEFORE ME this 7th day of July 2018 in Naguilian, La
Union, Philippines, by the affiant who is known to me on the basis of competent document
shown as proof of her identity.