GAWAD KALASAG OMNIBUS SWORN STATEMENT FOR THE

CERTIFICATION OF AUTHENTICITY AND VERACITY OF

DOCUMENTS

I, [NAME] , Filipino, of legal age, with permanent address at

[ADDRESS] , do hereby depose and state under oath:

1. That I am the [Mayor/Local DRRM Officer/Local DRRM Staff duly

authorized by the Local DRRM Officer] of [NAME OF LGU,
PROVINCE] ;
2. That I have conducted an honest self-assessment of my Local DRRM Council/Office using
the prescribed Local DRRM Office/Council Assessment Tool, pursuant to the NDRRMC
Memorandum Circular No. 001, s. 2023;
3. That each of the document submitted is a true and faithful reproduction of the original,
complete and that all statements and information provided therein are true and accurate;
4. That all the information provided in the document is within the prescribed assessment
period, covering January 2022 to December 2022;
5. That I am assuming full responsibility and accountability on the validity and authenticity
of the documents submitted;
6. That I am aware that any violation thereof will automatically disqualify the Local
Government Unit from the Gawad KALASAG selection process;
7. That I am making these statements as part of the requirement for the Gawad KALASAG
Seal for Excellence in Disaster Risk Reduction and Management and Humanitarian
Assistance.

[NAME]
[City/Municipal Mayor/Local DRRM Officer]
[NAME OF LGU, PROVINCE]

SUBSCRIBED AND SWORN to before me this ______ day of ___________, 20___ at

_______________________, Philippines. Affiant exhibited to me his/her [ID TYPE], with his/her
photograph and signature appearing thereon, with ID No. _______________________, issued on
____________ at ________________________.

NOTARY PUBLIC