Annex A

Republic of the Philippines

COMMISSION ON ELECTIONS
Manila

STATEMENT OF CANCELLATION

I, ____________________________________________________________
(name of candidate), of legal age, Filipino, and resident of
_______________________________________________________________,
under oath, state as follows:

1. On _______________________, I filed my Certificate of Candidacy

for the position of ________________________ before the Office of
the Election Officer of _______________.
2. Also, on ___________________________, I filed my Certificate of
Candidacy for the position of ________________________ before
the Office of the Election Officer of _______________.
3. After much thought, I am hereby cancelling my Certificate of
Candidacy for the position of _____________________________and
thereby retaining my candidacy for the position of
___________________________.

IN WITNESS WHEREOF, I hereunto affix my signature this ___ day

of _________ 2016, in ________________, Philippines.

________________________________________
(Name and Signature of Candidate, and Date)

SUBSCRIBED AND SWORN to before me this ___day of ________ 2016, at

___________________, affiant exhibiting to me an Identification document/card which
contains a photograph and signature bearing No. ____________________ issued by
__________________ on _______________.

____________________________________
(Officer Authorized to Administer Oath)

Doc. No. ______;

Page No. ______;
Book No. ______;
Series 2016.

8/08/2016