REPUBLIC OF THE PHILIPPINES)

PROVINCE OF LA UNION ) Sc.

MUNICIPALITY OF TUBAO )
x-------------------------x

AFFIDAVIT OF CHANGE OF BODY

KNOW ALL MEN BY THESE PRESENTS:

I, FELIX U. CORPUZ, of legal age, married, Filipino citizen and a resident of

Magsaysay, Tubao, La Union after having been duly sworn to in accordance with law, do hereby
depose and state, that:

1. I am the owner of the following vehicle, more particularly described as follows:

MAKE----------------Kawasaki CT100S
TYPE ----------------Motorcycle without Side Car
CHASSIS No. ------- MD2A18AZ1EWD64801
ENGINE/MOTOR No. DUZWED19547
PLATE No.---------- AC 18088

2. That I have caused the change of the body of said Motor vehicle from its original
MOTORCYCLE WITHOUT SIDE CAR to TRICYCLE;

3. The changes mentioned above were not aimed to conceal a crime or violation of the
Land Transportation Code, Traffic Laws and Regulations or the Revised Penal
Code of the Philippines, but was principally for personal reason and satisfaction;

4. I am executing this Affidavit to attest to the truthfulness and veracity of the

foregoing narration of facts; and for whatever legal intents and purposes this may
well serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 12th day of August
2015 at Tubao, La Union, Philippines.

FELIX U. CORPUZ
Affiant
SSS 03-2642755-8

SUBSCRIBED AND SWORN to before me this 12th day of August 2015 at Tubao,
La Union by the affiant appearing personally and who is known to me to be the same person
who executed this affidavit.

ATTY. JOONEE RANDYL E. RIVERA

Notary Public
Doc. No. 224; until December 31, 2016
Page No.: 45; Aspiras Highway, Francia Sur, Tubao, La Union
Book No.: VI; Roll No. 61766, TIN 929-347-628
Series of 2015. PTR No. 9680876; 01-06-15, Tubao, LU
IBP Lifetime OR No. 933274; 01-02-14, SFLU