Republic of the Philippines

City of Cebu

AFFIDAVIT OF DAMAGE TO VEHICLE

I, Henry A. Busque, Filipino, of legal age, single, and own Driver of my new
sedan car with home address Casili Cambiohan Consolacion Cebu, 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 18 February 2017, at around 9:30 pm, I was driving my car, 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 San fernando Street going to dalaguete
Cebu, a 15 wheeler truck which was on my front lane going to south cebu also, suddenly
I over took because the big truck was at very slow speed because and it was fully loaded.
And then when I was over took I gave signals to the big truck I thought he will give way
just like to the other cars that overtook but suddenly he increased the speed and it was
night time and the road was not so big thats why I decreased the speed and going to his
back again and the bad news is our right side mirror and front bumper was hit because
after I proceeded to his back he change the speed I thought he will stop because it was
very slow again but it didnt gave signals or anything As a result, the entire right side
mirror broke off from the said cars and also in my front right side was hit in the back of
the truck and since the big truck was still moving forward, he increased the speed and left
us in the road. I try to take the plate number but it was far already.

4. That the said driver of the big truck drove away without acknowledging the
incidents, therefore, a case of hit and run that even the plate number of the 15 wheeler
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 22 day of February,

2017 at City of Cebu, Philippines.
 HENRY ANDRINO BUSQUE

SUBSCRIBED AND SWORN to before me, this __ day of February 2010, by

NERIO M. PEREGRINO who exhibited to me his drivers 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.