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Republic of the Philippines

City of Paraaque

)
)S.S

AFFIDAVIT OF LOSS / ACCIDENT


I, ALDRIO MONTERO GABAYNO, of legal age, Filipino, and with postal
address at 181 San Roque Street, Barangay San Antonio Valley 6, Paraaque City,
after having been sworn in accordance with law, hereby depose and state, that:
1. My brother, AMER M. GABAYNO, is the registered owner of a motor vehicle, which is
more particularly described as follows:
MV FILE NO.
PLATE NO.
DENOMINATION:
MAKE:
SERIES:

1356-00000113163
TRO 288
SUV
Mitsubishi
Montero Sport G

2. Last September 15, 2016 at around 6 oclock in the morning, I borrowed the abovementioned motor vehicle;
3.

While was slowly driving along San Antonio Valley 2 towards Sucat Road,
a mountain bike which was on the parallel lane, suddenly cut my lane at the drivers
(blind) side, and hit the left side of door of the vehicle, causing obvious marks or
scratches were caused thereto;

4. Unfortunately however, the said passenger mountain bike owner swiftly drove
away without acknowledging its liability despite the fact that I called his attention;
5. Worse, I was not able to run after him because it was traffic that time, and I chose
not to leave the said motor vehicle on the road;
6. I am executing this Affidavit to attest to the truth and veracity of the foregoing and
for whatever legal intent or purposes it may duly serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 26 th day of
September 2016 at City of Paraaque, Philippines.
ALDRIO MONTERO GABAYNO
Affiant
SUBSCRIBED
and
SWORN
to
me
this
______________
at
____________________, the affiant exhibiting to me his Professional DL with No.
N03-94-176990 as competent proof of identity.
Doc No. ___
Page No. ___
Book No. ___
Series of 2016

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