Republic of the Philippines)
City of Malolos) S.S.
I, _______________________________________, of legal age, residing at
_____________________________________________ after having been sworn in accordance
with law, depose:
1. that I am the owner/duly authorized representative (incase of corporation attach the
board resolution authorizing him/her to execute this document) of the
building/structure/facility to be erected/renovated/repaired/modified located at
_________________________________________________.
2. That the estimated amount of building/structure/facility to be
erected/renovated/repaired/altered/modified/change of occupancy is
Php_________________________________________________ (Amount in words)
3. That I declare, under the penalties of perjury, the above information are verified by
me, and to the best of my knowledge are true and correct or based on authentic
documents.
Witness my hand this ____ day of __________ 2019.
________________
Affiant
SUBSCRIBED AND SWORN TO before me this __ day of _____________ 2019 2019 at
_________________________, Bulacan.
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