Republic of the Philippines

Department of Labor and Employment

National Capital Region
Manila Field Office
Election Challenge Form
Name of Challenger:
Challenged Voter:
Voter Reference Number:

_________________________

Ballot Number:

_________________________

Reason/s for the Challenge:

______________________________
______________________________
CERTIFICATION

I, the undersigned, attest that the information I have provided is true and accurate to the best of
my knowledge under the penalty of Perjury. I certify that I have read and understood the election
rules as provided by the Department of Labor and Employment.
Signature of challenger:

The following are the explanation and supporting grounds for the challenge in relation to the
Certification Election held at Our Lady of Lourdes Hospital at Sta. Mesa, Manila on July 31, 2014, to
wit:

I hereby reserve the right to file the necessary petition or motion to further support this challenge.

Received by:

________________

Date:

________________ Time: _______________