Republic of the Philippines )

AFFIDAVIT OF ACCIDENT

I, ___________________., of legal age, single and residing at _____________________, after

having been duly sworn to in accordance with law, do hereby depose and say:

1. I am the owner of a motor vehicle, more particularly described as follows:

Make and Model:

Model Number:
Chasis Number:
Engine Number:

2. I am holder of Non-Professional Driver’s License with license Number ______/

3. On September 17, 2012, I drove my car to San Fernando City to report for work. I
arrived in the city at around 8:50 A.M.

4. Before I went to our office, I proceeded to Jollibee located in Jose Abad Santos
Avenue (JASA) in San Fernando City to buy my breakfast via its “Drive Thru”
service. After buying my breakfast and as I was slowly proceeding out of the
“Drive Thru” area to prepare for a right turn to join the flow of traffic going to the
west towards the JASA-McArthur Highway intersection, a speedy motorcycle
came from the opposite direction which was on the wrong lane and hit my vehicle.
The lady driver of the motorcycle immediately fell with her vehicle and badly hit
the ground.

5. Concerned about the lady driver and thinking that she was injured, I immediately
alighted from my car to help her and check her condition. Fortunately, the lady
driver was not injured and she was able to get up with the help of a tricycle driver.
She told me that she was okay although I can see by the expression on her face that
she was in pain. After the lady driver was able to get up and lift up her motorcycle,
I then checked my vehicle if it sustained any damage. I looked at the side of my
vehicle hit by the motorcycle and I did not see any scratch or damage. The tricycle
driver who helped the lady driver even commented “wala namang tama, sir.”
(there’s no damage, sir). I then bid the lady driver goodbye and cautioned her to
take care and be mindful of road safety next time. Thinking that she was not
injured and that my vehicle did not sustain any damage, I did not bother to get the
lady driver’s personal information nor the plate number of her motorcycle.

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 6. Upon reaching the parking lot _______________________. I told her about the
accident and she also inspected my car. She noticed some minor damage on my
car and she pointed to me that my car sustained some scratches on the bumper
and its headlight. That is when I realized that the accident has caused damage to
my vehicle. Attached to this affidavit are photographs of the damages on my
vehicle due to the accident.

7. I am also attaching to this affidavit the affidavit of the tricycle driver who
witnessed the accident to attest to the truth of the facts stated herein.

I am executing this affidavit to attest to the truth of the foregoing facts for whatever legal
purpose this may serve.

Affiant Further Sayeth Naught.

Affiant

SUBSCRIBED AND SWORN before me this 19th day of September 2012, affiant exhibiting
to me his Driver’s License No N01-12-017982 issued at Quezon City with expiry date on
March 3, 2015.

Notary Public

Doc No. ……..:

Page No. ………;
Book No. ……..;
Series of 2012.

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