CONTRACTOR'S AFFIDAVIT OF PAYMENT

The under signed hereby certifies that payment has been made in full and all obligations have
otherwise been satisfied for all materials and equipment furnished, for all works, labor and
services performed, and for all known indebtedness and claims against ___________________
for damages arising in any manner in connection with performance of the Contract referenced
above for which the Owner or Owner's property might in any way be held responsible or
encumbered.

Issued this _____day ____________, 2021 for the purpose of securing payment for our
Progress Billing No. ______dated September 14, 2021.

Contractor:

General Manager, CLLC

Subscribed and sworn to before me this day of ____________in Quezon City, Philippines.

Doc No.: ____________

Page No.: _____________
Book No.: _____________
Series of 2021