Republic of the Philippines)

Province of Quirino) S.S.

Municipality of Diffun
x - - - - - - - - - - - - x                                                 

SWORN STATEMENT

I, RUBEN V. DELA CRUZ, of legal age, Filipino citizen, and a resident of

Brgy. Rizaluna, Cordon, Isabela, after first having been duly sworn to in
accordance with law, hereby depose and say:
1. That I am the one and the same person the foregoing;

2. That I am the Treasurer of Brgy. Rizaluna, Cordon, Isabela;

3. That on April 26, 2021, at around 04:00 in the afternoon, when I was
rendering my official duty at the Barangay, one of my constituents came
to secure Barangay Clearance and when I was about to issue official
receipt, I discovered that there was no available (OR) Accountable Form
51 thereat. I immediately went home to fetch the remaining AF 51 form
being kept thereat bearing number 13655351 - 13655400 and I rushiedly
went back at Barangay outpost. And when I was about to reach for the
said OR I discovered that the same was no longer in my possession and I
believed to be lost on my way to the office;

4. I declare that the statements made in this affidavit are true and correct
and I am willing to bear all the legal responsibilities arising therefrom.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this 24th day of
June, 2021 at Diffun, Quirino, Philippines.

RUBEN V. DELA CRUZ

Affiant
Prof. Driver’s License No. B12-15-001758
Valid until 2023/08/17

SUBCRIBED AND SWORN TO before me this 24th day of June, 2021 at

Diffun, Quirino, Philippines, by affiant who is personally known to me and
personally signed the foregoing instrument before me and avowed under penalty
of law to the whole truth of the contents of said instrument.

WITNESS MY HAND AND SEAL.

MA. KAREN A. BALDONADO-GUILLERMO

Notary Public-Notarial Commission No. 02-2019
Doc. No. 273; Until December 31, 2021
Page No. 55; PTR No. 9460968/01-04-2021
Book No. XXX; Lifetime IBP No. 17396/05-26-2017
Series of 2021. ROLL No. 67812/05-26-2017
MCLE Compliance No. VI0013817/Valid until April 2022
Andres Bonifacio, Diffun, Quirino