REPUBLIC OF THE PHILIPPINES

Quezon City

)
) S.S.

AFFIDAVIT OF DAMAGE TO VEHICLE

I, ROBERTO F. ORTIZ of legal age, Filipino, married, residing at 32 Aspen Suite,
Barangay San Antonio, Quezon City, after having been sworn in accordance with law,
do hereby depose and state that:
1. That I am a duly-licensed driver in accordance with pertinent Land Transportation
laws, rules and regulations, and was issued a corresponding Driver's License with
number NO2- 07-001245 which is valid until 23 September 2016;

2. That on 23 September 2014, at around 10:30 pm, I was driving a vehicle

owned and registered in my name which is more particularly described as
follows:
Make:
Series:
Body Type:
MV File No.:

TOYOTA
CAMRY
SEDAN
1340-00000407896

Engine No.: L13Z1-2300605

Chassis No.: PADGG21309V000456
Plate No.:
POL586

3. I was driving the aforementioned vehicle along Quirino Avenue heading to Roxas
Boulevard. At the corner of Quirino Avenue and A. Mabini Street, I stopped,
after the traffic light turned red. When the traffic light turned green, I
signalled, and took a left turn. As I was approaching A. Mabini Street, a
speeding red Toyota Tamaraw with plate number OVA699, driven by Michelle C.
Tan of legal age residing in 85 Balintawak Street, Brgy. San Pedro, Pasig City, with
Non-Professional Drivers License No. NO2-80-233376, suddenly and recklessly
barged in. She was driving along the opposite side of Quirino Avenue (coming

from Roxas Boulevard), and took a hasty right turn toward A. Mabini Street,
unaware that I had already taken the left turn. Although I made a sudden
brake as I saw her vehicle coming in, she still bumped my car. Hence, both of our
vehicles sustained damages.
That said Driver's License has not been confiscated by the LTO, Police or other Traffic
Enforcers for any traffic violation;
4. A traffic enforcer, Matthew J. Lapuz, went quickly to the scene, and led me

and Ms. Tan to his station. As we arrived, he encouraged us to discuss a

possible settlement; stating that if we could not agree on a settlement, he
would take us to the police station at Port Area so that the police could
prepare a report.

5. Ms. Tan later acknowledged her recklessness, and asked for a settlement to

which I informed her that it would be of the amount of P3,000.00. We left

the station after informing Mr. Lapuz that a settlement has been reached.
FURTHER AFFIANT SAYETH NAUGHT.

MICHELLE C. CHOA
Affiant
SUBSCRIBED AND SWORN TO before me this 16TH day of December 2014,
affiant exhibiting to me her Passport No. EA123666, issued by the Department of Foreign
Affairs in Manila on 12 December 2013, at the place before mentioned.

Atty. NEL PATRICK J. RAMOS

Notary Public
Commission (Serial) No. 12345
San Antonio City
Until 31 December 2014
Roll of Attorneys No. 42345
IBP No. 23456/1-06-14/San Antonio
PTR No. H-456789/1-06-14/San Antonio

Doc. No. _____

Page No. _____
Book No. _____
Series of 2014.