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    Affidavit of Accident - Baltazar

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    joonee09
    Charlie Baltazar was in a motorcycle accident on May 27, 2013 in Tubao, La Union. He lost control of his motorcycle due to a brake failure and suffered a fractured left clavicle. He was taken to Ilocos Training and Regional Medical Center and admitted. Baltazar signed an affidavit on June 28, 2013 to attest to the details of the accident in support of his application for sick leave from SSS. The affidavit was notarized by Atty. Joonee Randyl E. Rivera.

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    Affidavit of Accident - Baltazar

    Uploaded by

    joonee09
    90 views1 page
    Charlie Baltazar was in a motorcycle accident on May 27, 2013 in Tubao, La Union. He lost control of his motorcycle due to a brake failure and suffered a fractured left clavicle. He was taken to Ilocos Training and Regional Medical Center and admitted. Baltazar signed an affidavit on June 28, 2013 to attest to the details of the accident in support of his application for sick leave from SSS. The affidavit was notarized by Atty. Joonee Randyl E. Rivera.

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    Affidavit of Accident- Baltazar

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    Charlie Baltazar was in a motorcycle accident on May 27, 2013 in Tubao, La Union. He lost control of his motorcycle due to a brake failure and suffered a fractured left clavicle. He was taken to Ilocos Training and Regional Medical Center and admitted. Baltazar signed an affidavit on June 28, 2013 to attest to the details of the accident in support of his application for sick leave from SSS. The affidavit was notarized by Atty. Joonee Randyl E. Rivera.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    90 views1 page

    Affidavit of Accident - Baltazar

    Uploaded by

    joonee09
    Charlie Baltazar was in a motorcycle accident on May 27, 2013 in Tubao, La Union. He lost control of his motorcycle due to a brake failure and suffered a fractured left clavicle. He was taken to Ilocos Training and Regional Medical Center and admitted. Baltazar signed an affidavit on June 28, 2013 to attest to the details of the accident in support of his application for sick leave from SSS. The affidavit was notarized by Atty. Joonee Randyl E. Rivera.

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    © All Rights Reserved
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    Download as docx, pdf, or txt
    of 1

    REPUBLIC OF THE PHILIPPINES)

    Province of La Union ) Sc.


    Municipality of Tubao )

    AFFIDAVIT OF ACCIDENT
    KNOW ALL MEN BY THESE PRESENTS:

    I, CHARLIE Z. BALTAZAR, of legal age, single, Filipino citizen and a resident


    of Francia West, Tubao, La Union, after having been duly sworn to in accordance with
    law, do hereby depose and state, that:

    1. I am a security guard employed by Metroguard Security Agency currently


    assigned at Jollibee Agoo;

    2. Sometime in the afternoon of May 27, 2013, while maneuvering my


    motorcycle at a sharp curve in Brgy. Francia West, Tubao, La Union, I lost
    control of my motorcycle caused by a brake loss causing the following injury:
    “FRACTURE, CLOSED, COMPLETE DISPLACED M/ 3rd CLAVICLE LEFT;

    3. As a result of the above-mentioned accident, I was taken to the Ilocos


    Training and Regional Medical Center and was admitted as an OPD Patient
    on May 27, 2013, a Medical Certificate to that effect is hereby attached for
    reference;

    4. I am executing this Affidavit of accident to attest to the truthfulness and


    veracity of the foregoing narration of facts; for the purpose of supporting my
    application for sick leave with the SSS; and for whatever legal intents and
    purposes this may well serve.

    IN WITNESS WHEREOF, I have hereunto set my hand this 28th day of June 2013
    at Tubao, La Union, Philippines.

    CHARLIE Z. BALTAZAR
    Affiant

    SUBSCRIBED AND SWORN to before me this 28th day of June 2013 at Tubao, La
    Union, Philippines. Affiant, whom I personally know through his UMID ID No. CRN
    0111-0068967-6, signed the document in my presence and avowed under penalty of law
    to the whole truth of the contents of the foregoing document.

    ATTY. JOONEE RANDYL E. RIVERA


    Notary Public
    Doc. No.: ______; until December 31, 2014
    Page No.: ______; Aspiras Highway, Francia Sur, Tubao, La Union
    Book No.: _____; Attorney’s Roll No. 61766, April 25, 2013
    Series of 2013. PTR No. 8284603; 04-18-13, Tubao, La Union
    IBP No. 671319; 04-03-13, San Fernando, La Union

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