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