C E R T I F I C A T E

This is to certify that Mario G. Lipana, of 20 A. Sandoval Avenue, Palatiw, Pasig City,
the registered owner of an Chevrolet Cruze with registered plate number PCO-851,
has not collected nor filed any claims from his own insurer in view of the damage
caused to his motor vehicle in a collision incident which occurred last ______________
as recorded in Report No. ___________________ filed at _______________ Police Station.



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MARIO G. LIPANA