Affidavit Of Accident- Barcena.docx

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: BODY: ENGINE NUMBER: SERIAL/CHASSIS NO.: PLATE NO.:

MITSUBISHI WAGON 4D56-AAB0724 PAEVB5NJ18B012306 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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