REPUBLIC OF THE PHILIPPINES )

CITY OF DASMARINAS ) S.S.

AFFIDAVIT OF INCIDENT / CAR DAMAGE

I, RHODORA SANGALANG BORILLA, of legal age, Filipino, married, and a resident of

Block 6 Lot 1 Palosapis St., Dasmarinas City, Cavite, Philippines, 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/SERIES: HONDA CITY

ENGINE NO: L15Z17401080
CHASSIS NO. PADGM6620LV618674
MV FILE NO. 1301-00001428860
PLATE NO. NDM 5473

2. That I am the authorized driver of the said vehicle;

3. That on December 10, 2020 at around 10:00 a.m., I properly parked the said vehicle in the
parking lot of Robinsons Place-Imus. Unfortunately, when I got back to the vehicle at around
6:00 p.m., I noticed that the said vehicle has already attained some damages which were incurred
by an unidentified person; the tail light lid is broken, rear bumper and outer rear panel need
polishing due to scratches;

4. 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 29 th day of December 2020 at

Dasmarinas City, Cavite, Philippines.

RHODORA SANGALANG BORILLA

Affiant

SUBSCRIBED AND SWORN to before me on the day and place above written, affiant
exhibiting to me his/her Temporary Driver’s License (Non-Professional DL) no. D06-08-009747

Doc No. 402

Page No. 81
Book No. 09
Series of 2020