Republic of the Philippines )

_____________________________ ) S.S.

SWORN STATEMENT of
ACKNOWLEDGEMENT
with UNDERTAKING TO PAY
I, JEFF CHUA, of legal age, Filipino, single and a resident of Bulacan Bulacan,
after being duly sworn to, under oath and in accordance with law, do hereby
depose and state that:

1. I am presently employed as Collector of ABCD Enterprises;

2. I was issued a motorcycle service, particularly described as follows:

Honda TMX 125 Motorcycle
Temporary Plate Number: 3210-345
Engine number: ABCD12343
Frame No. : ABCSD16734
CR No.: 3465787
OR No.: 1234454

3. I have entrusted the abovementioned Motorcycle for repair at the repair

shop of my brother, Donald Triump located at Maybato Del Monte;

4. The abovementioned Motorcycle can no longer be found at the repair

shop of my brother, believed to have been stolen;

5. I undertake and promise to pay the cost of the lost/stolen motorcycle

under my custody in the amount of ONE HUNDRED THOUSAND PESOS
(100,000.00) and hereby consents to the paymment through salary
deduction in the amount of ________________ every payday until fully paid;

6. In the event that my employment from abcd enterprises is severed for

whatever reason, I undertake and promise to pay the outstanding
balance in full before my severance from the company;

7. I voluntarily execute this affidavit and fully understands the contents

thereof.
 IN WITNESS WHEREOF, I hereunto affix my signature this ______ day of
__________ 2022, at _______________________________________.

Jeff Chua
Affiant

SUBSCRIBED AND SWORN TO before me this __________ day of

____________________, 2022 at ______________________, affiant having exhibited to me
his __________________________________ as a proof of competent identification.

Doc. No.
Page No.
Book No.
Series of 2022.