REPUBLIC OF THE PHILIPPINES } NATIONAL CAPITAL REGION} QUEZON CITY } AFFIDAVIT OF NO COMPREHENSIVE CAR INSURANCE 1, Amold T. Carag, of legal age, Filipino, Married and resident of 15 Golden Lane St. Morning. Star, Culiat, Quezon City, after having been duly swom to in accordance with law, depose and state that: 1. Lam a duly licensed driver with LTO Driver's License with NoNO293211056 2. That on June 23, 2019 at around 11:40 AM, I was driving a motor vehicle registered in my name which is more particularly described as follows: ‘owned and Make: Hyundai Model: Elantra Chassis: KMHDG41CACU193468 _| Engine: G4FGBU258310 Plate number. TOI 689 ‘Year Model: 2011 3. That while I was driving the said vehicle along North Ave. Quezon City, northbound, my car was suddenly hit by a vehicle behind me. 4. The vehicle who caused damage to my vehicle is owned by Leslie Y. Arellano and is more particularly described as follows: Make: Toyota ‘Model: Fortuner (Chassis: MHFHA3ESSIO567143 | Engine: 1GD4504806 Plate number: NBE 7014 “Year Model: 2018 5. Asa result of the incident, my vehicle sustained damages particularly on the left tail light which was broken and indented rear bumper comer on the driver’s side. 6. That as of the present time, the vehicle above described, which I own, is not under any comprehensive vehicle insurance by any insurance company; 7. That I am executing this Affidavit to attest the truth of the foregoing and for any other purpose this affidavit may serve. 8. Affiant further sayeth naught IN WITNESS WHEREOF, [have hereunto set my hand this 7% dayof_VUtY 2019 in Quezon City, Philippines. = Sige Eig kORS Lo RERORE NE ANG nen peaslic FOR AND UN MANILA, Atbrne stale Buk 08 BARS. ZASAY CITY / WETRO Mant oP NOfOs: nn wofos7a27 -01703/19 pace veut itn, 20007 OHVosnoee @ Row wo r679 1/2022