Republic of the Philippines }

Province of Davao del Norte } S.s.

X----------------------- x

AFFIDAVIT OF ACCIDENT

I, MARIO SAMBILAD, 52 years old, Filipino, married and a resident of

Mangagoy, Bislig City, Agusan del Norte upon oath in accordance with law, do
hereby depose and say, THAT:

1. I am the authorized driver of one motor vehicle which is particularly

described as follows:

MAKE AND MODEL: MITSUBISHI

BODY: WAGON
ENGINE NUMBER: 4D56-AAB0724
SERIAL/CHASSIS NO.: PAEVB5NJ18B012306
PLATE NO.: SHF101

2. On January 18, 2018, around 7:15 o’clock in the morning, I was

driving the above described vehicle onboard with four passengers
en route from Tagum City, Davao del Norte bound to Provincial
Capitol of Compostela Valley, Cabidianan, Nabunturan, ComVal ;

3. That upon reaching the curve road, an accident prone area of P-2
Barangay New Sibunga, Nabunturan Compostela Valley, the said
vehicle accidentally hit by a stone (pebble) coming from
unidentified motor vehicle running in opposite direction;

4. As a result thereof, the front windshield of the forenamed vehicle

particularly the center portion incurred un estimated cost of
damage for repair and/or replacement;

5. I am executing this affidavit to inform the concerned agencies of

the foregoing facts and to attest to the truth thereof and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

___________________ at ___________________ Philippines.

MARIO SAMBILAD
Affiant
Driver’s License No. L06-15-000692

SUBSCRIBED AND SWORN to before me this ______________at _____________

with competent proof of identity.

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