REPUBLIC OF THE PHLILIPPINES )

)S.S.

AFFIDAVIT OF CHANGE OF BODY DESIGN OF

MOTORCYCLE

I, GRACIANO I. SAMSON JR., of legal age, Filipino, single, and a resident of #23 M.
Tuazon St. Pascual Compound, Parang Marikina City, after having been duly sworn to in
accordance with law do hereby depose and say:

1. That I am the legal owner and possessor of a motorcycle particularly described as:

MV FILE NO.: 0356-00000131095 ENGINE NO.: KB509E344180

CHASIS NO.: KB509344160 MAKE: HONDA
SERIES: TMX1559 BODY TYPE: MOTORCYCLE
YEAR MODEL: 2012 DENOMINATION: TRICYCLE
PLATE NO: 1922SX

That I caused the change of the body type of the above-described motorcycle from
WITH SIDECAR to WITHOUT SIDECAR.

2. That I execute this affidavit to attest to the truth of the above facts and
circumstances and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 14 th day of JULY, 2020 at
____________________________.

GRACIANO I. SAMSON JR.

Affiant
Driver’s License No. D16-94-107453

SUBSCRIBED AND SWORN to before me this ______________________

at__________________.

Doc. No.
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Book No.
Series of 2020