REPUBLIC OF THE PHILIPPINES )

GUAGUA, PAMPANGA ) S.S.

AFFIDAVIT OF CHANGE BODY DESIGN

I, ____________________________________, of legal age, Filipino Citizen, with

residence at ______________________________________________________________
after having been duly sworn to in accordance with law do hereby depose and state:

1.) That I am the owner of a certain motor vehicle more particularly described as follows:

Make and Type : ________________________________________________

Motor No. : ________________________________________________
Chassis No. : ________________________________________________
Plate No. : ________________________________________________
File No. : ________________________________________________
Color : ________________________________________________

2.) That I caused the change of body of the above – mentioned motor vehicle from
____________________________________ to ______________________________________;
and

3.) That the said motor vehicle will be utilized for ___________________________
purposes and now running on its new type of body ___________________________________
and found to be roadworthy;

That I have executed this affidavit to testify under oath the truth and veracity of the
foregoing statements.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of

___________________ at Guagua, Pampanga.

__________________________________
AFFIANT

Identification Document ___________________________________________________

SUBSCRIBED AND SWORN to before me on this ______ day of

_______________________ at Guagua, Pampanga. Affiant exhibited to me his Identification
Document stated below his name.

Doc No. ______

Page No. _____
Book No. _____
Series of 2021.