REPUBLIC OF THE PHILIPPINES

PROVINCE OF BOHOL
CITY OF TAGBILARAN

AFFIDAVIT
FOR CHANGE OF MOTOR VEHICLE BODY

I, REMEDIOS R. FUDALINO, of legal age, married and a resident

of 187-A, VP Inting St., Poblacion, Tagbilaran City, Bohol, Philippines,
after having been duly sworn to in accordance with law, do hereby
depose and state:

1. That REMEDIOS R. FUDALINO, the registered owner of motor

vehicle described as follows:

Make: KAWASAKI
Engine No: BC175AEBA2121
Chassis No: BC17H-B86947
MV File No: 0701-00000983684

2. That the registration of the said vehicle is still classified as

private and denomination as motorcycle without side car, but it
is the intention of the owner to change the said vehicle into for
hire;

3. That we hereby affirm that the said motor vehicle shall be

converted to tricycle for hire which shall be assembled with side
car bearing Body No. 0022 under the franchise issued by the
local government of Tagbilaran City;

4. That the change of motor vehicle is not intended for any illegal
or unlawful purpose but solely due to forgoing reason;

5. As such, I am executing this affidavit in good faith to attest to

the truthfulness of the foregoing fact, and for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

December 13, 2019 at Tagbilaran City, Philippines.

REMEDIOS R. FUDALINO
Affiant
Philhealth: 12-2526682841-6
Issued by Philhealth

SUBSCRIBED AND SWORN to before me this December 13, 2019

in the City of Tagbilaran, Bohol, Philippines. Affiant exhibited to me his
competent proof of identity previously written.

Doc. No. 98; Page No. 20; Book No: IV; Series of 2019.