REPUBLIC OF THE PHILIPPINES)

CITY OF MASBATE ) S.S.

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AFFIDAVIT OF CHANGE COLOR

I, NIOGAN, GENESIS L. , of legal age, Filipino, (single/married/widow) and a resident of PUROK 5

BUENAVISTA, USON, MASBATE, after having been duly sworn to in accordance with law, depose and
state THAT:

1. I am the registered owner of a motor vehicle which is particularly described as follows:

Make & Type : SUZUKI/BURGMANSTREET

Motor Number : AF21 - 3025504
Chassis Number : EA11Z - 129355
Plate Number : 102EWW
MV File No. : 0501 - 00000726350
Year Model : 2023
Color : BLACK

2. The original color of the said motor vehicle was "BLACK";

3. When the paint of the above-described motor vehicle had faded, I had its color repainted to
"BLUE/BLACK/WHITE" such that the color of the said motor vehicle was changed from "BLACK" to "
BLUE/BLACK/WHITE ";

4. Said change of color is not intended for any illegal or unlawful purpose but solely due to the foregoing reasons;

5. I am executing this Affidavit to attest to the truth of the foregoing and in support of the application for the change
of color of the above-described motor vehicle on its Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Masbate City, Philippines.

SUBCRIBED AND SWORN TO before me this ___________________ in _________________, Philippines,

affiant exhibiting to me his/her competent evidence of identity by way of __________________ issued at
______________ on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 20__