REPUBLIC OF THE PHILIPPINES )

PROVINCE OF )S.S.
MUNICIPALITY OF )
x--------------------------------------------x

SWORN STATEMENT

I, ________________________, of legal age, married, Filipino citizen and resident of

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

1. That I am the Chairman of the Board _____________________________ with address

at ______________________________;

2. That as such, said Civil Society Organization is an independent, non-partisan

organization;

3. That as Chairman, I vouched to retain its autonomy while pursuing the

advancement of peoples’ interest through its membership in a local special body, after
satisfying all the requirements and set criteria as stated in DILG Memorandum Circular
No. 2019-72 and after securing a Certificate of Accreditation from the concerned
Sanggunian;

4. That I executed this sworn statement in compliance of the requirements in

securing accreditation of Civil Society Organizations (CSO’s) and for whatever legal
purposes this may serve.

5. That all the statements above are true and correct to the best of my knowledge
and belief.

IN WITNESS WHEREOF, I have hereunto set our hands this 15th day of August
2019 at ____________________________.

____________________________
Affiant

SUBSCRIBED AND SWORN to before me this 15th day of August 2019 at

______________________ affiant exhibited to me her ___________________.

Doc. No._________;
Page No._________;
Book No._________;
Series of 2 0 1 9 .