REPUBLIC OF THE PHILIPPINES)

CITY OF ___________S.S.

AFFIDAVIT

I, (Name of Contractor), of legal age, with postal address at (Address of the Contractor), after having
duly sworn in accordance with law, hereby depose and say:

That I am the General Manager of (Company), a Filipino corporate duly organized under the existing
laws of the Philippines with business address at (Address).

That (Company) has a contract with the Republic of the Philippines under (Implementing Agency).

That the said Contract is for (Project Title).

That in the compliance with Department Circular No. 17 Series of 1996, (Company), hereby states the
gross receipts has been declared with the Bureau of Internal Revenue for Income Tax Purposes;

That we have not given any money or gift, nor made promises to any persons employees, or officer of
the Local Government Unit in connection to the said project;

That, (Company), has fully paid all workers/laborers, subcontractor, suppliers and all persons or parties
who have done or furnished materials supplied services, and other inputs or work accomplished on the
project.

That affidavit is being executed to support our claim for the First Progress Billing for work
accomplishment above said project and to comply with the legal requirements.

IN WITNESS WHEREOF, I have unto affixed my signature this _________ of ____________ 2019
at (Place where this Affidavit is signed)

___________________________
Affiant

SUBSCRIBE AND SWORN to before me this ______ day of _________, at _____________, affiant
is exhibiting to me his Tax Identification Card No. _______________ issued
______________________

Doc. No. ____________

Page No. ____________
Book No.____________
Series of 2019.