REPUBLIC OF THE PHILIPPINES )

Municipality of Dasmarinas ) S.S.

Province of Cavite )

AFFIDAVIT OF INCIDENT / CAR DAMAGE

I, MARLIT DE GUZMAN NUQUE, of legal age , Filipino, and a resident at Blk 6 Lot 12 Heneral
Uno, Pason Kawayan II, Gen. Trias, Cavite, after having been duly sworn to in accordance with law, hereby
depose and say:

1. That JULY JOY A SALURIA, the registered owner of a motor vehicle specifically described as
follows:

MAKE: FORD FIESTA 5 DR MID

BODY HATCHBACK
ENGINE NO: UEJDHK29104
MV FILE NO: 1301-00001032645
MODEL No 2018

2. That on June 07, 2019 around 7PM. That I was driving along Soriano Hi-way, and stucked
in a intersection due to stop light, and when the signal turns to green light, a car in-front
drove into reverse gear, and accidentally bumped our vehicle. Front bumper of the said
vehicle were damaged; The incident was hit and run;

3. That on July 30, 2019 around 4AM. That I was driving along Pasong Kawayan II, and the
road was too dark, I didn’t notice that there was a steel pipe in our way, which I accidentally
bumped it. the vehicle sustained some damages in the right portion, whereas the side mirror
and the right front passenger of the vehicle;

3. That I am executing this affidavit to attest to the truth of the foregoing facts and for all and
purposes the same may be used and for INSURANCE CLAIM PURPOSES;

IN WITNESS WHEREOF, I hereby affix my signature this 30th day of July 2019 at
Dasmarinas City, Cavite, Philippines.

MARLIT D.NUQUE
Affiant

SUBSCRIBED AND SWORN to before me on the day and place above written, affiant
exhibiting to me his/her Non-Professional Driver’s License No. C09-10-000227.

Doc No. 391

Page No. 79
Book No. 01
Series of 2019