REPUBLIC OF THE PHILIPPINES)

PROVINCE OF NUEVA VIZCAYA) S.S.

MUNICIPALITY OF BAYOMBONG)

AFFIDAVIT

I, ____., of legal age, married and resident of Tandang Sora, Quezon City, after
having been sworn to in accordance with law, hereby depose and state:

That I am the owner of a Motorcycle which I bought which is described as

follows:

Make: Yamaha Serial/Chassis No.

Type: Motorcycle Engine No.
Plate No. No plate available

That due to color deterioration, I caused the repainting of the above-

mentioned van from Grey to Blue.

That in am executing this affidavit to attest to the truth of the foregoing facts and
to inform the Land Transportation Office as regards the changing of color of the
above described van and further executing this affidavit for whatever legal
purpose/s it may serve.

IN TESTIMONY WHEREOF, we have hereunto affixed our signatures this 14th day of
October, 2019 at Bayombong, Nueva Vizcaya.

Affiant
Lic. No.

SUBSCRIBED AND SWORN to before me this 14th day of October, 2019 at

Bayombong, Nueva Vizcaya.

WITNESS MY HAND AND SEAL.