Annex “A-1”

Republic of the Philippines

COMMISSION ON ELECTIONS
Manila

AUTHORITY TO SUBMIT STATEMENT OF

CANCELLATION
I, ____________________________________________________________
(name of candidate), of legal age, Filipino, and resident of
__________________________________________________________________
hereby authorize ________________________________________________
with address at ___________________________________________________
to submit my Statement of Cancellation.

IN WITNESS WHEREOF, I hereunto affix my signature this ___ day

of _________ 2016, in ________________, Philippines.

_____________________________________________
(Name and Signature of Candidate, and Date)

__________________________________________________
(Name and Signature of Agent, and Date)

SUBSCRIBED AND SWORN to before me this ___day of ________ 2016,

at ___________________, affiant exhibiting to me an Identification
document/card which contains a photograph and signature bearing No.
____________________ issued by __________________ on _______________.

________________________________
(Officer Authorized to Administer Oath)
Doc. No. ______;
Page No. ______;
Book No. ______;
Series 2016.

8/08/2016