Republic of the Philippines) S.S.

City of ___________ x--------------x AFFIDAVIT OF DAMAGE TO VEHICLE I, NERIO M PEREGRINO, Filipino, of legal age, married, and COMPANY DRIVER of BOROUGH FINANCING CORPORATION with office address at Unit 2105 Antel Global Corporate Center, Julia Vargas Avenue, Ortigas Center, Pasig City, Philippines, after being duly sworn to in accordance with law, hereby depose and state: 1. That I am a duly licensed driver with Professional Driver's License No. N02-90144465 which is valid until 12 May 2011. 2. That on 23 February 2010, at around 7:30 pm, I was driving a vehicle, with Ninna G. Castro in the passenger’s seat, owned and registered in the name of Borough Financing Corporation which is more particularly described as follows: Make: HONDA Engine No.: L13Z1-1400806 Series: CITY Chassis No.: PADGM16409V000546 Body Type: SEDAN Plate No.: ZTL177 MV File No.: 1340-00000409599 3. That while I was slowly driving along Santolan Street, Cubao towards EDSA, a passenger Jeepney which was on the opposite lane going to Katipunan Road, suddenly over took our traffic lane and the spare tire posed at the driver’s side of the jeepney hit the left side mirror of our company vehicle. As a result, the entire left side mirror broke off from the said car’s body and since that passenger jeepney was still moving forward, the detached mirror was dragged onto the left side of our car causing dents and further damage; 4. That the said passenger jeepney drove away without acknowledging its liability, therefore, a case of “hit and run” that even the plate number of the jeepney was impossible to be ascertained; 5. That there were no traffic enforcers at the time of the accident; 6. That I am executing this Affidavit to attest to the truth of the foregoing and in support of the claim against the insurer for the repair of the damage caused to the said company vehicle. )

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of February, 2010 at City of___________, Philippines.


by NERIO M. Notary Public Doc. ______. Philippines on May 12.SUBSCRIBED AND SWORN to before me. No. Book No. PEREGRINO who exhibited to me his driver’s license with license number N02-90-144465 issued at East Avenue. this __ day of February 2010. Page No. 2011. Quezon City. . Series of 2010. 2008 and which will expire on May 12. ______. ______.

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