COMMISSION ON ELECTIONS

May 9, 2022 FORM

National and Local Elections SAC
Summary Report of Advertising Contracts
NAME OF MEDIA ENTITY: STATION/OFFICE:

Name of Authorized
Representative: (SURNAME) (FIRST NAME) (MIDDLE NAME) (EXT) JOB TITLE/POSITION:

Office Address:
NAME of PAYOR / CLIENT / AD
E-mail Address: AGENCY Telephone/Mobile
NAME of CANDIDATENo.:or PARTY

CONTRACT RECEIPT CONTRACT PARTICULARS AMOUNT /

CONTRACT DATE
NUMBER NUMBER (medium,period,frequency,duration,timeslot,etc) VALUE

(Paid (Political Ad Beneficiary)

For Ad)

CERTIFICATION AND ACKNOWLEDGMENT

The undersigned, being the duly authorized representative of after being duly sworn, do hereby certify that:
SUBSCRIBED AND SWORN TO before me (Date of Oath)
(1) the foregoing advertising contracts listed herein were made for the purpose of the elections; and
this affiant exhibiting his/her expiring on
(2) that all the information provided and stated in this report are true and correct. (Gov't-Issued Identification) (ID Number)

, and issued by .
DATA PRIVACY ACT (Expiry Date of ID) (Issuing Government Agency)
The undersigned consents on the general use and sharing of information obtained in this disclosure
and its attachments for legitimate purposes.
Doc. No.: ______
Page No.: ______
Book No.: ______
DATE SIGNED Series of ______ NOTARY PUBLIC