C

Sta

PART A
NAME OF
CANDIDATE: (SURNAME)

Candidate Type: (Mark INDEPENDENT (no political party nomination)

with "X")
WITH POLITICAL PARTY NOMINATION (CONA
NAME OF PARTY:

(For candidates with CONA)

(CO
ELECTIVE POSITION:

Home/Office Address:
NUMBER STREET NAME

DATE OF RALLY:

PART B: CONTRIB
DATE OF RECEIPT OF RECEIPT CONTRIBUTOR'S TAXPAYER ID
CONTRIBUTIONS NUMBER No. (TIN)

PART C: EXPENSE
DATE EXPENSE WAS RECEIPT BUSINESS FIRM/
INCURRED NUMBER CONTRACTOR'S TIN
 PAR

I hereby certify that: (1) the expenses listed in Part C were made by me as candidate or by my du
the contributions listed in Part B were received by me as candidate or by my duly authorize
specified above are true & correct; (4) both contributions & expenses are supported by receipts,
(5) the expenses were incurred in accordance with the Omnibus Election Code & other pertinent
 COMMISSION ON ELECTIONS
May 13, 2019
National and Local Elections
Statement of Expenses on Public Rally

PART A: PERSONAL INFORMATION OF THE CANDIDATE

(FIRST NAME) (MIDDLE NAME)

T (no political party nomination) E-MAIL ADDRESS:

CAL PARTY NOMINATION (CONA) CONTACT NUMBER:

(COMPLETE NAME OF PARTY)

District/City/Municipality/ Province/Region :

BUILDING/SUBDIVISION BARANGAY

Rally Venue & Address:

PART B: CONTRIBUTIONS RECEIVED BY CANDIDATE FOR THE PUBLIC RALLY

NAME OF CONTRIBUTOR ADDRESS OF CONTRIBUTOR

TOTAL CONTRIBUTIONS (IN CASH & IN

PART C: EXPENSES INCURRED BY THE CANDIDATE FOR THE PUBLIC RALLY

NAME OF BUSINESS FIRM OR ADDRESS OF BUSINESS FIRM OR
CONTRACTOR CONTRACTOR

TOTAL EXPE
 PART D: CERTIFICATION & ACKNOWLEDGMENT
SUBSCRIBED & SWORN TO befor
affiant exhibiting his/her
made by me as candidate or by my duly authorized representative; (2)
candidate or by my duly authorized representative; (3) all entries
expenses are supported by receipts, invoices, & similar documents; (Expiry Date of ID)
ibus Election Code & other pertinent laws.
Doc. No.: ______
Page No.: ______
Book No.: ______
DATE SIGNED Series of 2019.
ELECTIONS
9
Elections
n Public Rally

N OF THE CANDIDATE

(ACRONYM)

CITY/MUNICIPALITY PROVINCE/REGION

NDIDATE FOR THE PUBLIC RALLY

CONTRIBUTION TYPE
ADDRESS OF CONTRIBUTOR
(Cash/In-Kind)

TAL CONTRIBUTIONS (IN CASH & IN KIND) RECEIVED FOR THE PUBLIC RALLY

DIDATE FOR THE PUBLIC RALLY

ADDRESS OF BUSINESS FIRM OR
DESCRIPTION OF EXPENSE
CONTRACTOR

TOTAL EXPENSES INCURRED FOR THE PUBLIC RALLY

KNOWLEDGMENT
SUBSCRIBED & SWORN TO before me this

(Gov't-Issued Identification) (ID Number)

, and issued by
(Issuing Government Agency)

NOTARY PUBLIC
 FORM
SER-C

(ACRONYM)

PROVINCE/REGION

AMOUNT / VALUE

₱ -

AMOUNT

₱ -
 expiring on

.
(Issuing Government Agency)

NOTARY PUBLIC