REPUBLIC OF THE PHILIPPINES )

) S.S.

AFFIDAVIT

I, _________________________________________, Filipino, _____ years old, and with address at

___________________________________________________________, after having been duly sworn to in accordance with
law, do hereby depose and state:

1. I am a registered voter for the 2016 National and Local Elections at Precint No. _____, Clustered Precint
_____________, Polling Place _________________________________, District _____________, City of _____________,
Province of _____________, as can be show in in the Election Day Computerized Voter’s List (EDCVL);

2. On 9 May 2016, at around ______ a.m. / p.m., I duly cast my vote for the 2016 National and Local Elections at the
above stated polling place.

3. At the time I casted my vote:

 Initially, the proceedings appeared to be in order. However, while waiting for the printing of the voter’s receipt
by the VCM, I noticed a discrepancy between the actual votes that I casted and the votes that appeared in the
voter’s receipt. Specifically, I voted for Ferdinand “Bongbong” R. Marcos, Jr. for vice-president by fully shading
the oval beside his name in my ballot. Upon reading the voter’s receipt, the name of
_________________________ was indicated as my choice for vice-president.

I immediately called the attention of the BEI regarding this discrepancy and I was allowed to register my objection
by printing my name and affixing my signature on the voter’s receipt, which I returned to the BEI.

 Initially, the proceedings appeared to be in order. However, while waiting for the printing of the voter’s receipt
by the VCM, I noticed a discrepancy between the actual votes that I casted and the votes that appeared in the
voter’s receipt. Specifically, I voted for Ferdinand “Bongbong” R. Marcos, Jr. for vice-president by fully shading
the oval beside his name in my ballot. Upon reading the voter’s receipt, the name of
_________________________ was indicated as my choice for vice-president.

Despite calling the attention of the BEI to said discrepancy, they refused to register and note my objection against
the discrepancy.

 I was not allowed to print and sign my name on the voter’s receipt.

 The BEI tore the voter’s receipt, making it impossible for me to register my objection against the
discrepancy.

 After casting my vote, the following irregularities transpired:

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_________________________________________________

4. I am executing this affidavit to attest to the truth of the foregoing statements, in support of my protest against the
fact that the voter’s receipt does not reflect the votes that I actually cast during the 9 May 2016 elections and for whatever
legal purpose it may serve.

IN WITNESS WHEREOF, I hereby set my hand this ______________________ at the _____________________.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____________________ at ____________________________, affiant

exhibiting to me his/her _______________ valid until _______________.

Doc. No. ___;

Page No.___;
Book No.___;
Series of 2016.