ANNEX “A”

SWORN STATEMENT

KNOW ALL MEN BY THESE PRESENTS:

I, ___________________, in my capacity as _______________________ of

____________________, with business address _________________, do hereby certify that
the (describe specific transaction subject of the request for treaty relief), is not under any of
the following:

1. Investigation or on-going audit;

2. Administrative protest;
3. Claim for refund or issuance of a tax credit certificate, judicial
or administrative protest;
4. Collection proceedings; or
5. Judicial appeal

This certification is being issued as a requisite in the application for tax treaty relief with the
International Tax Affairs Division of the Bureau of Internal Revenue.

IN WITNESS WHEREOF, I have signed this Certification on this ______ day of _________,
20___in _______________.

(Notary Public)