REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ISABELA )S.S.

MUNICIPALITY OF ROXAS )
X-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-x-X

AFFIDAVIT OF CHANGE BODY DESIGN

I, JIMMY S. TAN, of legal age, Filipino citizen, married and a resident of Bantug,
Roxas, Isabela, after having been duly sworn to in accordance with law, do hereby depose
and say:

That I am the registered owner of a certain motor vehicle which is more particularly
described and identified, as follows:

MAKE/SERIES ----------- FUSO/CANTER

TYPE OF BODY ----------- DROPSIDE TRUCK W/ CRANE
SERIAL/ CHASSIS NO. ----------- FG337B-440123
MOTOR NO. ----------- 4D33-774464
PLATE NO. ----------- WOV839

That I have caused the change of the BODY DESIGN of the said vehicle from
DROPSIDE TRUCK W/ CRANE TO DROPSIDE TRUCK done by a trusted
mechanic;

That I am executing this affidavit in good faith, attesting to the truth of all the
foregoing statements made above, informing the authorities concern of the changed
of the BODY DESIGN of my above-described vehicle DROPSIDE TRUCK W/ CRANE
TO DROPSIDE TRUCK, for proper recording and for all legal intents and purposes it
may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 10 th day of January 2018 at
Roxas, Isabela.

JIMMY S. TAN
Vendor
Driver’s License No. B12-97-001002
Valid Until 2022-09-28

SUBSCRIBED AND SWORN to before me this 10th day of January 2018 at Roxas,
Isabela.

ATTY. GERONIMO I. VENTURA III, LLM

Notary Public
Doc. No.211 Until December 2018
Page No.44 IBP Lifetime Member 012154
Book No.02 Roll of Attorneys No. 51885
Series of 2018 MCLE Compliance No. V00006334
PTR No. PGI 9329125