REPUBLIC OF THE PHILIPPINES )

CITY OF DASMARIÑAS ) S.S

PROVINCE OF CAVITE )

AFFIDAVIT OF INCIDENT / CAR DAMAGE

I, LEA ROSE CENENO LOLENG, of legal age, Filipino, single, and a resident of Blk 6 Lot 5,
Narra St. Andreaville Salitran IV, Dasmarinas City, Cavite, after having been duly sworn to in
accordance with law, hereby depose and say:

1. That I am the registered owner of a motor vehicle specifically described as follows:

MAKE: MITSUBISHI/ MIRAGE G4 GLX

COLOR VIRGIL GRAY
YEAR MODEL: 2019
CONDUCTION STICKER NO;B5T115

2. That on July 18, 2019 around 7:00 pm. That I properly parked the said vehicle in our home,
and when I came back, I noticed that there was a damage in the right side passenger side dent
and scratches of the said vehicle, no one saw what happen, resulting for hit and run incident;

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 25th day July 2019 at
Dasmariñas City, Cavite, Philippines.

LEA ROSE CENTENO LOLENG

Affiant

SUBSCRIBED AND SWORN to before me on the day and place above written, affiant
exhibiting to me his/her UMID ID NO;0111-489560-4

Doc No.306
Page No. 62
Book No.01
Series of 2019