REPUBLIC OF THE PHILIPPINES

MUNICIPALITY OF TALAVERA )
PROVINCE OF NUEVA ECIJA ) S.S.

AFFIDAVIT

I ___Rogelio C. Pallarca____ of legal age, married, Filipino, with postal address at Don Mariano
Marcos, Poblacion, Jaen, Nueva Ecija after having duly sworn to in accordance with law, hereby
depose and say;

That I am the ____Authorized Managing Officer____ of _____ R.C. PALLARCA CONSTRUCTION______

(Designation) (Construction Firm Name)
A Filipino entity duly recognized under the existing laws of the Republic of the Philippines
with business address at _________Don Mariano Marcos, Poblacion, Jaen, Nueva Ecija.__________

That the said contract is for Contract ID No.: ______19CE0146_________

________________________CONSTRUCTION OF MULTI PURPOSE BUILDING ________________
____________________Sitio Pao, Brgy. San Antonio Weste, Lupao, Nueva Ecija_______________
(Name of Project)

That in compliance with Department Circular No. 17 Series of 1996, the R.C. PALLARCA CONSTRUCTION
(Construction Firm)
hereby states the gross receipts has been declared with the Bureau of Internal Revenue for Income Tax
purposes;

That we have submitted our Monthly Certificate Payment No. ____ for our construction works for the
period covering from ____________ to ______________

That we have not given any money or gifts, nor made promises of anything to any person, employees or
officers of the Department of Public Works and Highways in connection to the said project.

That R.C. PALLARCA CONSTRUCTION has fully paid all workers/laborers, sub-contractors, suppliers,
and all persons or parties who have done or furnished materials, supplied services and other inputs on
work accomplished on the project as of _____________ and such payments were all in accordance
with law;

That this affidavit is being executed to support our claim for ______ for works accomplished in the
above said project and to comply with the legal requirements.

IN WITNESS WHEROF, I have affixed my signature this __________ day of __________, 2019 at
________________________

________________________________
ROGELIO C. PALLARCA
Affiant

SUBSCRIBED AND SWORN to before me this ________ day of _____________, 2019 at

______________________ affiant exhibited to me his Res. Cert. No. 27329426 dated January 18,
2019, issued at Jaen, Nueva Ecija.

Notary Public

Doc No. ______

Page No. _____
Book No. _____
Series of 2019