ANALYSIS OF CAPITAL STRUCTURE

I. NAME OF CORPORATION :

II. APPLICATION :

III. VERIFICATION :

A. RETAINED EARNINGS
Amount
Unappropriated Retained Earnings per (year) Audited
Financial Statements
Add: Reversal of appropriated retained earnings on (date)
Less: Stock dividends declared on (date)
Balance

B. AUTHORIZED CAPITAL STOCK

Shares Par Value Amount
Authorized Capital Stock per (year) Audited Financial
Statements
Submitted application to Securities and Exchange
Commission (SEC) - Decrease in Par Value
With application for Increase in Authorized Capital Stock -
for submission to SEC

C. SUBSCRIBED CAPITAL STOCK

Shares Par Value Amount
Authorized Capital Stock (with application for increase in
ACS)
Less:
Subscription of Capital Stock per (year) Audited
Financial Statements
Stock dividends declared on (date)
Balance
Unissued Capital Stock (with application for increase in
ACS)
Unaccounted Issuance of Shares -

The abovementioned data are true and correct and that all the requirements for stock
dividend declaration under Section 42 of the Revised Corporation Code of the Philippines have been
complied with.

SUBSCRIBED AND SWORN to before me this _____________ in ___________, Metro

Manila, affiant personally appeared and presented to me his _____________________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2021.