REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ANTIQUE ) S.c.

MUNICIPALITY OF SAN JOSE )
x------------------------------------------------------x

AFFIDAVIT

That I, JUAN MIGUEL REYES y SANTOS, of legal age, married, Filipino, and a resident of San Jose,
Antique, after being duly sworn to in accordance with law, hereby depose and say the following:

That I am the owner of a Yamada Motorcycle with Side Car, most particularly described as
follows:

Make Yamada
Type of Body Motorcycle with Side Car
Year Model 2006
Chassis No. 4FP-297267
Engine No. 4FP-297267
Plate No. 1234FA

That I am attaching herewith a machine copy of the Original Receipt and Certificate of
Registration issued by the Land Transportation Office as proof of my ownership over the
above-described motorcycle;

That the said motorcycle was involved in a incident on January 20, 2018 at Sitio Lubak, San Jose,
Antique. Please refer to the copy of the police blotter herein attached;

That my motorcycle was put into custody by the elements of the PNP San Jose after the
incident;

That this motorcycle is being used by our family so as to earn an income hence I am fervently
requesting the good police officers to release said motorcycle in my favor;

That I undertake to bring the motorcycle to court ordered by the competent authority and
promises not to dispose/deliver/assign/waive/mortgage the same at any time during the
investigation/pendency of the complaint.

That to ensure the integrity and preserve the identity and present state of the vehicle.

IN WITNESS WHEREOF, I have hereunto affix my signature this 29th day of January 2018 at San
Jose, Antique, Philippines.

JUAN MIGUEL S. REYES

Affiant
Senior Citizens ID No. 6807

SUBSCRIBED AND SWORN to before me this 29th day of January 2018 at Kalibo, Aklan,
Philippines by the affiant Juan Miguel S. Reyes with his Senior Citizen ID No. 6807, who personally
signed the foregoing affidavit before me and acknowledged that he executed the same and that he
understood the contents of the same.

NOTARY PUBLIC
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2018.