REPUBLIC OF THE PHILIPPINES )

PASIG CITY ) S.S.

AFFIDAVIT OF ACCIDENT

We, ERICK MAGPAYO y NIDEA, Filipino, of legal age, married, and

residing at No. 110 Robles St., Manggahan, Pasig City, after having sworn in
accordance with law, do hereby depose and state that:

1. My wife, Rowena Magpayo, and I are the owners of Suzuki Swift Dzire
with plate no. UD 7880. The car, however, was registered under the
name of my wife. As proof thereof a copy of the OR CR is hereto
attached as Annex “A”. ;

2. On or about 8:30 in the evening on March 30, 2017, we parked the said
car in front of Lucky Gold Plaza to buy something in a nearby grocery.
However, when we went out of Lucky Gold Plaza to get our car, we
found out that there was a dent and several scratches in our car;

3. The barker told us that a tricycle sideswiped our car while the same
was parked in front of the Lucky Gold Plaza. Unfortunately, the barker
was not able to get the plate number of the tricycle;

4. I am executing this Affidavit to attest to the truth of the foregoing facts

and for whatever purpose/s it may duly serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, we hereby affix my signature this 31 st day of

March 2017 at Pasig City.

ERICK N. MAGPAYO

Affiant

SUBSCRIBED AND SWORN to before me this 31st day of March 2017

in Pasig City, Philippines, affiant exhibited to me as competent evidence of
identity his Professional Driver’s License with No. D19-04-000956 issued by
the Land Transportation Office.

ATTY. MARCELINO C. ARCE, IV

Public Attorney II
Notary Public
(pursuant to RA 9406)

Doc. No._____;
Page No._____;
Book No. _____;
Series of 2017.