Republic of 

the Philippines )
City of Butuan ) S.S

SWORN STATEMENT
 
I, _________________,  of legal age, married with postal and residence address at
_________________________________________, after being duly sworn to in accordance with
law, hereby depose and state that:
 
1. I am an employee of the Local Government Unit (LGU) of La Paz, Agusan del Sur;
2. There is no complaint(s) against the undersigned pending with the Civil Service Commission,
Office of the Ombudsman, any Prosecutor’s Office, Department of Justice, or any regular courts
or the Court of Appeals and the Supreme Court; or pending administrative case with LGU La
Paz or any Administrative body; and
3. I am executing this sworn statement to lend to the veracity of the foregoing statement and for
whatever legal purpose or purposes that it may serve; 
AFFIANT FURTHER SAYETH NAUGHT.
IN WITNESS WHEREOF, I have hereunto set my hand this 18th of August at Butuan
City, Philippines.
 
         ________________
         Affiant
 
 
SUBSCRIBED AND SWORN to before me this____ of _________ by affiant exhibited
to me his/her ____________ issued at _____________ City on ________________.
 
Doc. No. ______;
Page No. ______;
Book No.______;
Series of  ______.