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REPUBLIC OF THE PHILIPPINES)

CITY OF ILIGAN ) S. S.

AFFIDAVIT OF ACCIDENT

I, ANA KATHRINA B. MANERE, of legal age, single, and a resident of Block 3


Lot 4 Emily Homes Subdivision, Lower Balulang, Cagayan de Oro City, after having been
duly sworn to an oath in accordance with law, hereby depose and say, that:

1. I am the registered owner of a SUZUKI ERTIGA, the specification of which


are as follows:

Make : SUZUKI
Model : ERTIGA 2017
Color : PEARL WHITE
Engine No. : K14BT1203154
Plate No. : ADO 8022

2. On December 24, 2017 at about 10:00 o’clock in the morning, my mother


requested me to buy vegetables and some meat at the wet market in
Carmen. When I arrived there, I noticed it was more crowded than the
usual and there were several cars parked at almost every corner, so, I
settled to park on a narrow space fronting UNITOP – Carmen branch;

3. After buying all the things I need, I immediately went home to cook for
lunch. When I went back to the car to get something, I discovered
that my car had a large dent and scratches at the lower back portion;

4. Since I could no longer check who caused the damaged because there
were no CCTV cameras in the area, I opt to claim damages with my
Insurance Company; and

5. This Affidavit is executed to attest to the truth of the foregoing statement


and for purposes of filing insurance claim on the said damages caused
by the accident.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my


signature this 1st day of February, 2018, at Cagayan de Oro City, Philippines.
ANA KATHRINA B. MANERE
Affiant

SUBSCRIBED AND SWORN to before me on the date and place above-written


by the Affiant.