REPUBLIC OF THE PHILIPPINES )

CITY OF DIPOLOG ) SS.

AFFIDAVIT OF DAMAGE TO VEHICLE

I, SHEENA MARIE EMORECHA PANONG, Filipino, of legal age, married, and a

resident of Gulayon, Dipolog City, Zamboanga del Norte, after having been duly
sworn in accordance with law, hereby depose and say:

1. That I am a duly licensed driver of a private owned company vehicle with

a corresponding detail:
MAKE: TOYOTA VIOS 1.3 E ENGINE NO: 1NRX053607
MV FILE NO: 1301-00000753578 YEAR MODEL: 2017
CR NO: 261227595 PLATE NO:
CHASSIS NO: PA1B19F32G4008331
OWNER: BPI CENTURY COKYO LEASE & FIN CORP LEASED TO
WYETH PHILS INC.;

2. That on August 30, 2019, at around 3:30 in the afternoon when I was
about to aboard my vehicle which was properly parked along Padre
Ramon St., Estaka, Dipolog City, I discovered the huge dent and skid
marks on the right/passenger’s side of my vehicle. Attached herewith is
a photo of the damage of the vehicle at the time of my discovery;

3. That according to the witnesses, it was an Elf truck with an unidentified

driver that caused the damage to the vehicle while trying to maneuver
out in the parked area. Then, the driver of the Elf truck left the scene
immediately after;

4. That there were no traffic enforcers at the time of the incident;

5. That I am executing this affidavit to attest to the truth of the foregoing

and in support of the claim against the insurer for the repair of the
damage caused to the said vehicle.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ______ day

of _______________ 2019 at Dipolog City, Philippines.

SHEENA MARIE E. PANONG

Affiant
PRC ID NO. 0782274

SUBSCRIBED AND SWORN TO before me this _______ day of _______ 2019 in Dipolog
City, affiant personally known to me, having exhibited to me his/her ID mentioned above,
bearing his/her photograph and signature.

Doc. No____ NOTARY PUBLIC

Page No____
Book No ____
Series of 2019