Republika ng Pilipinas

National Irrigation Administration

(Pambansang Pangasiwaan ng Patubig)
Lungsod ng Quezon
Office Address: National Government Center
EDSA, Diliman, Quezon City, Philippines
Telephone Nos.: (02) 929-6071 to 78 Telefax No. (632) 928-9343
Website: www.nia.gov.ph TIN No. 000-916-415

Republic of the Philippines )

of ) S. S.
Province of ____________ )

CONTRACTOR’S AFFIDAVIT

I, ________________________ of legal age, Filipino and resident of

__________________________, after having been duly sworn in accordance to law,
hereby depose and say:

1. That I am the _____________________ of ______________with Office

Address at _________________________;

2. That ______________________ has Contract with the Republic of the

Philippines under the National Irrigation Administration (NIA);

3. That the said Contract is for the Construction of _____________________

____________________________________________________________
__________________________________;

4. That ______________________________ has presented a percentage of

accomplishment of said project to the National Irrigation Administrator;

5. That ____________________________ has fully paid al labor, materials,

equipment rentals and government taxes incurred in connection with this
project;

6. That _____________________________ further certify that we have not

given or promised to give money or gift to any official or employees of the
government to receive this claim; and.

7. That I have executed this Affidavit for the purpose of our collection under
Progress Billing No. _____ with the National Irrigation Administration in
connection with the said Contract.

IN WITNESS WHERE OF, I have hereto affixed my signature this ______ day of
____, in the City/Province of _________________.

______________________________
( Name and Signature of Contractor’s Project Manager)

SUBSCRIBED AND SWORN to before me this _____ day of _______ at

________________,

Doc. No. ________________,

Page No. ________________,
Book No. ________________,
Series of ________________,

NIA-EOS-ENG-CMD-INT-Form19 Rev.00