REPUBLIC OF THE PHILIPPINES )

MUNICIPALITY OF LOS BAÑOS ) S. S.

PROVINCE OF LAGUNA )
X - - - - - - - - - - - - -X

AFFIDAVIT on ACCIDENT

I, ELINOR TAGUMPAY LOPEZ, of legal age, widow, Filipino, and a

resident of Lopez Village, Bangkal extension, Barangay San Antonio,
Los Baños, Laguna, after having duly sworn in accordance with law, hereby
depose and say that:

1.) I am the driver of a motor vehicle more particularly described as

follows:

Make: Honda
Body type: hatchback
MV file: 1031-00000878634
Chassis no.: MRHGK5830HP000289
Denomination: car light
Series: Jazz
Year model: 2017
Plate number: NAH 1292
CR no.: 2727058204, dated 04/04/2017
OR no.: 1123640125, dated 04/03/2017
Registered owner: LOPEZ, LENARD L.

Insurer: MAPFRE INSULAR

MI-ID: LLL08281970-001
Policy no.: 1001710002492
Effectivity: 29 March 2017 until

2.) On 11 March 2019, 08 AM, I was driving along FT San Luis road going to
a friend’s house within the vicinity and was in the process of turning
left when I suddenly saw a tricycle on the opposite lane and it hit my
vehicle’ front part;

3.) I then got off from my vehicle and was about to talk to the tricycle
driver but he quickly turned and sped away, and I was unable to get the
tricycle’s plate number.

4.) I was left there in a bit of shock, looking at my damaged vehicle,

which had incurred a detached front bumper and dented hood near the
passenger’s side;

5.) I am executing this affidavit to state the circumstances of the said

accident and file a copy with the vehicle insurer so that repairs and
replacements may be made the soonest, and for whatever other legal
purpose/s it may serve;

Affiant further sayeth naught.

11 March 2019

______________________
ELINOR TAGUMPAY LOPEZ
Affiant
LTO ID card number:
D12-88-013809
Expires 01/09/2023
Professional

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 Sworn to and subscribed before me in the Municipality of Los Banos,
Province of Laguna, Philippines, the affiant having shown to me her LTO ID
card as pertinent proof of her identity, the serial number, expiry date,
and class of which appearing below hername and signature.

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