SWORN ACCOUNTABILITY STATEMENT OF PROPONENT

This is to certify that all the information and commitment in this

Report ( ) document for the are true, accurate and complete.
Should I/we learn of any information which would make this Report inaccurate, I/we shall
bring the said information to the appropriate EMB Regional Office.
Thereby certify that no DENR-EMB personnel were directly involved in the
preparation of this Report other than to provide procedural and technical advice consistent
with the guidelines in the DAO 03-30 Revised Procedural Manual.
I hereby bind myself/ourselves jointly and solidarity for any penalties that may be
imposed from any misrepresentations or failure to state material information in this
Report.
In witness whereof, I hereby set my hands this _________ day of
__________________ at __________________.

Proponent

ACKNOWLEDGEMENT

SUBSCRIBED AND SWORN TO before me this _______ day of ______________ ,2023,

affiant, exhibiting his/her Community Tax Certificate ___________________________
issued on ___________ at _______________.

________________
Notary Public
Doc. No. _______
Page No. _______
Book No. _______
Series of 2023