REPUBLIC OF THE PHILIPPINES )

) S.S.

AFFIDAVIT

I, NAGAN MU, of legal age, Filipino and resident of ADDRESS MU, after being duly
sworn to in accordance with law, hereby depose and state that:

1. I was present during the uncompleted execution of the Deed of Sale with
Assumption of Mortgage between NAGAN NA and NAGAN TI MAYSA on KAANU at
LUGAR;

2. I was there because NAGAN NA asked me to be her witness since she was
selling her car.

3. I actually signed as a witness on the deed or form that was provided;

4. When I signed as a witness, NAGAN NA has not yet signed above her name as
Vendor;

5. NAGAN NA did not continue to sign the Deed of Sale with Assumption of
Mortgage due to a disagreement or misunderstanding and lack of requirements on some
matters constituting the sale and we left LUGAR without her signing it;

6. I am executing this affidavit to attest the truth of the foregoing facts and to
inform the proper authorities and for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set our hand this ___th day of
_____________, 2018 at __________________, Philippines.

NAGAN NA
Affiant

SUBSCRIBED AND SWORN to before me this __th day of _____________, 20___ in

___________ City, personally appeared NAGAN NA exhibiting her ID ______________________
as her competent evidence of identity bearing her photograph and signatures.

NOTARY PUBLIC

Doc. No. ____

Page No. ____
Book No. ____
Series of 201__.