Name of the Procuring Entity:

Contract Reference Number: __________

Name of the Contract : __________
Location of the Contract : __________

Standard Form Number: SF-INFR-51

Revised On: August 11, 2004

AFFIDAVIT OF SITE INSPECTION

I_________________, of legal age, Filipino and residing at__________________, under oath, hereby
depose and say;

1. That I am the owner of the _________________with office address at __________________

2. That I have inspected the site for the proposed project:__________________, located at

3. That I am making this statement as a part of Technical Proposal of the ________________for

the_________________________.

IN FAITH WHEREOF, I hereby affix my signature this _______ day of _____________________ 20 ___
at _____________________________________ Philippines.

Municipal Engineer Affiant

SUBSCRIBED AND SWORN TO before me this ________, day of __________________, 20 __, affiant
exhibiting to me his/her Community Tax Certificate No. ___________issued on
_____________at_________________, Philippines.

__________________
Notary Public

Until : ____________
PTR No. : ___________
Date : ____________
Place : ____________
TIN : ____________
Doc. No. : _________
Page No.: _________
Book No.: _________
Series of : _________