REPUBLIC OF THE PHILIPPINES )

PROVINCE OF LAGUNA ) S.S.

CITY OF BIÑAN )

AFFIDAVIT OF DAMAGE TO VEHICLE

I, CARL ANTHONY G. REYES, of legal age,single, Filipino citizen, and with resident
at 1536, Dalandan St., Garcia Subd., San Antonio, 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 : 2024
Make : HYUNDAI
Plate No. : NIQ9641
COLOR : WHITE
BODY TYPE : MPV
Engine No. : G4FLQ273323
MV FILE No. : 136623000852467
CR No :
OR No. : 1366-000000466439

2. That on January 13, 2024 around 9:00 am at Biňan Olivarez, while I stopped at the intersection of
Olivarez near in Sto. Domingo, Someone tricycle passenger suddenly hit the left rear tail light of
our car without my prior awareness;

3. As a result of the accident, the left tail light was damage;

4. That the said Tricycle passenger drove away without acknowledging its liability
therefore, a case of “hit and run” that even the plate number of the tricycle passenger
was impossible to be ascertained;

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 18thday of
January 2024, at the City of Bińan, Laguna.

CARL ANTHONY G. REYES

Affiant

SUBSCRIBED AND SWORN TO before me this 18thday of January 2024, exhibited to me his
Driver’s License No. with No. D04-22-309488 as his competent evidence of identity.

WITNESS MY HAND AND SEAL on the date and at the place first above written.

Doc. No. 227

Page No. 46
Book No. I
Series of 2024