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Republic of the Philippines

National Police Commission


PHILIPPINE NATIONAL POLICE REGIONAL OFFICE 3
NUEVA ECIJA POLICE PROVINCIAL OFFICE
SANTA ROSA POLICE STATION
Santa Rosa, Nueva Ecija

POLICE REPORT

TO WHOM IT MAY CONCERN:

THIS IS TO CERTIFY that based on available records kept in this office as


shown on page 00011 docketed under Entry Number C-2023-03-0154 dated March 7,
2023, the following entries exist to wit:

(SELF-ACCIDENT)

On March 7, 2023, at about 12:20 PM, personally appeared to this office one
Keith Allen Garcia y Pineda, 19 years old, single, male, filipino, and a resident of Brgy
Poblacion Norte, Salcedo, Ilocos Sur with Driver’s License number A11-21-202823
which expires on Nov. 8, 2025 to report a self-accident that transpired along Sta Rosa-
Ft. Magsaysay rd. Brgy. Soledad, Sta Rosa, N.E on March 2, 2023 at about 10:00 AM
his driven vehicle one unit Yamaha NMAX bearing plate number 580ATR, Engine
number G3L8E-0474241 owned by Jose L Bilaoen Jr.

According to the reportee on said time date and place of the incident, while he
was traversing said road when unable to control his balance due to the uneven concrete
road that resulted in a crushed/accident.

As a result of said accident driver/victim sustained injuries in different parts of the


body while his driven vehicle incurred damage in different parts with an undetermined
amount.

In truth hereof, hereunto affixes his signature below.

Keith Allen Garcia y Pineda


Reportee

= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = == =
This police report is being issued this 7th day of March 2023 here at Santa Rosa,
Nueva Ecija upon the request of the party involved for whatever legal intent and
purposes it may serve.

Prepared by:

PSSg Jake O Antonio


Duty Investigator

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