Affidavit Of Accident - Rimaisa Masdal February 15, 2019 F.1.docx

REPUBLIC OF THE PHILIPPINES ZAMBOANGA CITY

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AFFIDAVIT OF VEHICULAR ACCIDENT I, RIMAISA MASDAL ISAHAC, of legal age, married and with residence address at Villa Teresa Subdivision, Barangay Divisoria, Zamboanga City, after having been duly sworn to according to law, hereby depose and state: 1.

That I am the registered owner of a motor vehicle which is specifically described as follows: MODEL MOTOR NO. CHASSIS NO. COLOR PLATE NO.

: : : : :

MITSUBISHI MIRAGE G4 GLX 1 3A92UBA6718 MMBSTA13AEH003172 RED AAF 6757

2.

That said motor vehicle figured in an accident on January 05, 2019, at around 5:00 p.m. in the afternoon, when I visited my brother, Yusop B. Masdal, and his wife, Mrs. Evelyn C. Masdal, at their house at Lustre Street, Barangay Sta. Catalina. The accident occurred while I was driving my car and upon entering my brother’s house through their gate. I was in a hurry at that time;

3.

That when I was about to enter the above-cited gate, the left front door of the car hit a portion of the gate causing it to be dented heavily, including damage to the left side mirror;

4.

That when I backed the car on reverse, the right rear door hit a portion of the gate that it had scrapes and gashes as well as small dents. In this particular maneuver, the rear bumper of my car also hit a portion of the gate that it incurred scrapes and gashes. Then I drove forward again and then the front bumper had been dented and scraped as well;

5.

That the above-cited occurrences happened in just one afternoon wherein afterwards, I have observed that the damage to the car was the following: a) Dents/Scrapes at Front Bumper Right Portion b) Dents/Scrapes at Front Door Left/Right c) Dents/Scrapes at Rear Door Left/Right d) Scrapes at Rear Bumper e) Scrapes at Rear Quarter Panel Right

6.

That the aforementioned situation was an accident beyond my control after exercising extraordinary care and diligence to safety; and

7.

That I am executing this affidavit in order to attest to the truth of the foregoing circumstances and for the purpose of reporting the matter to my insurance office for insurance claims.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of February, 2019 at the City of Zamboanga, Philippines. RIMAISA MASDAL ISAHAC Affiant

SUBSCRIBED AND SWORN to before me this ____ day of February, 2019, affiant exhibited a competent proof of her Identity with I.D. No. LTO No. JO4-14001906. Doc. No. _____ Page No. _____ Book No. _____ Series of 2019

Doc No. ____ December 31, 2019 Page No. ___ 2018 Book No. ____ 5, 2007 Series of 2019 0002021/4-15-16 to 4-14-19

ATTY. LOVELL C. ABAD Notary Public Notarial Comm. No. 26-2018 until PTR No. 1623721 dated January 5, Lifetime IBP No. 703682 dated June IBP Roll No. 48879/ MCLE No. V2nd Floor, JA Building, Governor Ramos Avenue Sta. Maria, Zamboanga City/0916-

477-5551