REPUBLIC OF THE PHILIPPINES )

_____________________________ )
_____________________________ ) S.S.

AFFIDAVIT

I, LANI-ROHANI M. KOUZBARY, of legal age, married with postal address at 100 Macapagal
Avenue, Camague, Iligan City, after having duly sworn to in accordance with the law, hereby depose and say:

That I am the Authorized Managing Officer KOUZBARY BUILDERS, a Filipino corporation duly organized
under the existing laws of the Republic of the Philippines.

That the KOUZBARY BUILDERS has a Contract with the Republic of the Philippines under the Department
of Public Works and Highways (DPWH) Region 10, Cagayan De Oro City.

That the said Contract is for 1K00292 – Construction along Tubod-Ganassi Road, Lanao del
nd
Sur 2 LD, K1610+772.846 - K1616 + 1000

That in compliance with Department Circular No. 17 Series of 1996, the KOUZBARY BUILDERS, hereby
states the gross receipts have been declared with Bureau of Internal Revenue for Income Tax purposes;

That, we have submitted our Monthly Certificate of Payment No. 4 for our construction works for the period
covering August 13, 2019 - September 23, 2019;

That we have not given any money or gift, nor made promises of anything to any persons, employees or officer
of the Department of Public Works and Highways in connection to the said project;

That KOUZBARY BUILDERS has fully paid all workers/laborers, subcontractor, suppliers and all persons or
parties who have done or finished materials supplied, supplied services, and other inputs on work accomplished on the
project as of August 13, 2019 - September 23, 2019;and such payments were all in accordance with law;

That this affidavit is being executed to support our claim for the Final for work accomplished anent above said
project and to comply with the legal requirements.

IN WITNESS WHEREOF, I have unto affixed my signature this 28th day of December 2020 at
Iligan City.

LANI-ROHANI M. KOUZBARY
General Manager

SUBSCRIBED AND SWORN to before me this ____day of _________ at

_________________________ Affiant exhibition to me his Res. Cert. No. __________ issued on
_______________ at ____________.

Doc. No. : __________________

Page No. : __________________
Book No. : __________________
Series of : _________________ __________________
Notary Public