REPUBLIC OF THE PHILIPPINES )

PROVINCE OF LAGUNA ) S.S.

CITY OF BIÑAN )

AFFIDAVIT OF DAMAGE TO VEHICLE

I, CHRISTINE C. DINGLASAN, of legal age, married, Filipino citizen,

and with resident at Block 3, lot 17, Woodside Vill, Canlalay, City of Binan,
Laguna, after having been duly sworn to in accordance with law, hereby depose
and state:

1. That, I am a authorize driver of the vehicle with the description below:

Model : 2013
Make : MITSUBISHI
Plate No. : UMQ761
COLOR : PYRENESE BLACK
BODY TYPE : HATCHBACK
Engine No. : 3AD2UAK3309
MV FILE No. : 1324-00000777907
CR No : 159458272
OR No. : 1324-000000372019

2. That on January 29, 2024 around 12:00 noon, I parked my car at Biňan Doctors
hospital, after I covered my target doctors in Binan Doctors hospital I was
shocked because I discovered that the vehicle has yellow paint and big dent on
the front and top of the car hood in left side in additional to that the front hood
was stacked and cannot be open,

3. As a result of the accident, the front hood was damage;

4. That is liability therefore, a case of “hit and run”;

5. That there were no traffic enforcers at the time of accident;

6. That I am executing this affidavit to attest to the truth of the foregoing facts 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 herein below

this 29thday of January 2024, at the City of Bińan, Laguna.

CHRISTINE C. DINGLASAN
Affiant

SUBSCRIBED AND SWORN TO before me this 29thday of January 2024,

exhibited to me his Driver’s License No. with No. N03-93-150994 as his competent
evidence of identity.

WITNESS MY HAND AND SEAL on the date and at the place first above
written.
Doc. No. 291
Page No. 59
Book No. I
Series of 2024