Republic of the Philippines ) City of Davao ) s.s x---------------------------------x AFFIDAVIT OF INCIDENT
I, EUFRACIO C. U, Filipino, of legal age, married, and a resident of L1, B1, Donasville Subd., Davao Cit, a!er "aving been s#orn to in a$$ordan$e #it" la#, do "ereb depose and state t"at% 1. &"at I am t"e aut"ori'ed driver of t"at motor ve"i$le registered under t"e name of m son-inla#, (eneroso . (alve' *r., #"i$" ve"i$le is spe$i+$all des$ribed as follo#s% / 0L&/ 2. 2D/L S/8I/S 0L&/ 2. /(I/ 2. CSSIS 2.
% undai % ( 3456 % 6517 % Santa Fe 6.6L8 % 9:;513 % D7BD<455663 % S
6. 2n *ul 4, 651> at around 16%1= in t"e a!ernoon, #"ile I #as ba$?ing along t"e "ig"#a at Brg. Lago, (lan, Sout" Cotabato, I a$$identall sides#iped t"e railing@barrier on t"e said "ig"#a, #"i$" I did not see from t"e rearvie# and side mirrorsA ;. &"e impa$t $aused a dent and s$rat$" on t"e rig"t side of t"e above des$ribed motor ve"i$le, par$ularl damaging t"e front and rear doors t"ereof, t"ereof, and also $aused a s$rat$" s$rat$" on t"e rig"t step-board, step-board, rear rig"t side s?irt, and rear rig"t #"eel rim of t"e said motor ve"i$leA 7. I am exe$ung t"is adavit to aest to t"e trut" of t"e foregoing $ir$umstan$es, $ir$umstan$es, for purposes of $laiming against t"e said motor ve"i$leEs insuran$e, and for #"atever legal purpose t"is ma serve. IN !ITNE"" #EREOF , I "ave "ereunto set m "ands t"is 11 t" da of *ul 651> at Davao Cit, 0"ilippines.
EUFRACIO C. U A$ant :alid ID% L&2 DriverEs Li$ense o% L5>->;-55146=
"U%"CRI%ED AND "!ORN to before me in t"e Cit of Davao t"is 11 t" da of *ul 651>, b aant #"o ex"ibited to me $ompetent eviden$e of "is ident, t"at "e is t"e same person #"o personall signed t"e foregoing adavit before me and a$?no#ledged t"at "e exe$uted t"e same.
NOTAR NOTAR PU%&IC PU%& IC
Do$ o. 0age o. Boo? o. Series of 6513
