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REPUBLIC OF THE PHILIPPINES) Fietdeblanca, Pampanga ss AFFIDAVIT OF LOSS 1 sr V-Sanghyr. _,oigegal age, Fiipino cttzen and a resident of 4 after being duly swom toin ice wit ), hereby dépose and J That, on Mah 4,202 at about A @ | was criving a motor vehicle described as folows: wes " 20d Te if E ont -ca -te YoarntaiarType = ff ag He, vias 13 ( ‘Serial No. We OVE Sal np 2424 poet ugh Policy No. [ ant longa = Espen Hey" Sheu sean cord te fon ( ct, dn tally bumped On He side ‘Ean dabic put Wk tuning int) ener: f ‘That | have executed this affidavit to attest the truth of the aforementioned acts under oath for insurance purposes. IN WITNESS WHEREOF, Mar in the City: ‘SUBSCRIBED AND SWORN to before ffi 3 120%, 20,18 2amann ga teistdgs zee exhibiting to me hisiher residence certificate no. Ol

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Acfrogdshi8d6ytewx09ivv Qmztge6a5imjo2frwlfds8492d2p72v Zux0abg3lgf8ehywviegg9stun9bjo1ji2bc5kr068ck9vu5h8lbizi 9je9v Ixflouulsqm3jpwb Jok3sh Qjqveq
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