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 COMPANYDRIVER of
BOROUGH FINANCING CORPORATION with office address at Unit
2105Antel 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. N02-90-144465 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.: PADGM16409V00546
Body Type: SEDAN
Plate No.: ZTL 177
MV File No.: 1340-00000-409599

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.

NERIO M. PEREGRINO
Affiant

SUBSCRIBED AND SWORN to before me this _______day of _____________, 20___ at

________________, Affiant exhibiting to me his/her Residence Certificate No./ Valid Identification
_____________________________ issued at _____________ on _____________________.
 NOTARY PUBLIC

Doc. No. _______

Page No. _______
Book No._______
Series of _______