REPUBLIC OF THE PHILIPPINES)

CITY OF ______________________)

AFFIDAVIT OF SELF ACCIDENT

I, ______________________ of legal age, Filipino, with residence address

at_____________________________________________________________, ________ City,
after having been duly sworn to in accordance with law, hereby, depose and say:

1. That I am the authorized driver of one motor vehicle which is particularly described as
follows:

PLATE NO: ___________

BODY TYPE:___________
MAKE: ___________
YEAR MODEL: ___________
ENGINE NUMBER:___________
CHASSIS NUMBER:___________

2. That on _______________, 2017 at around __ o’clock in the (morning/afternoon), I was

slowly driving along _______________________ at ______ City. When i am turning
right into a small alley of the said road, I accidentally hit a hard material or a wall that
may cause damages into my car vehicle;

3. That I just found out that the ___ and___ side portion of my vehicle was damaged.
Unfortunately, the accident happened so fast and it went beyond my control;

4. That I am executing this affidavit in good faith to attest to the truthfulness of the above
facts and to apprise the proper authorities concerned for whatever legal purposes this may
be serve.

IN WITNESS WHEREOF, I hereunto set my hand this __th day of _______ 2017 at
_______ City, Philippines.

_______________________
Affiant

SUBSCRIBED AND SWORN to before me this ____th day of _________ 2017 at _____
City. Affiant exhibiting to me her Valid ID No._________________.

Doc. No. ____;

Page No. ____;

Book No.____;

Series of 2017