REPUBLIC OF THE PHILIPPINES )

_________________________) SS.

CERTIFICATION UNDER OATH

I, Name of the Chairperson, Filipino, of Legal age, married, with address at

_______________________________, after having been duly sworn in accordance with law, hereby,
depose and say:

1. That I am the Chairman of the Board of Name of the cooperative, duly organized and existing
under the Cooperative Development Authority and laws of the Philippines with office address at
______________________________________________;

2. That the following names of the members with their corresponding capital contribution are as
follows:
Name of the Member Amount of Capital Contribution

3. That the said cooperative has applying for application for Certificate of Tax Exemption to the
Bureau of Internal Revenue under Revenue Memorandum Circular No. 102-2016 amending the
Revenue Memorandum Order No. 76-2010 and Revenue Memorandum Circular No. 81-2010

4. That this affidavit is being executed in order to attest to the truth of the foregoing circumstances
and for the purpose of complying with the requirement for applying said application

IN WITNESS WHEREOF, affixed hereto signature this ___________ at Davao City, Philippines.

NAME OF CHAIRPERSON
Affiant

SUBSCCRIBED AND SWORN to before me this ___________ day of ________________ exhibiting to me

his/her __________________________ issued on at _______________ in Davao City, Philippines,