COMMISSION ON ELECTIONS

FORM
October 30, 2023
Barangay and Sangguniang Kabataan Elections ROC
Report of Contributions
PART A: PERSONAL INFORMATION OF THE CONTRIBUTOR OR DONOR
CONTRIBUTOR'S
NAME:
(SURNAME) (FIRST NAME) (MIDDLE NAME)

Mobile/Phone Nos.:
CONTACT DETAILS:
E-Mail Address:

PERMANENT ADDRESS:
(STREET NO.) (STREET NAME) (BUILDING/SUBDIVISION)

(BARANGAY) (DISTRICT/AREA) (CITY/MUNICIPALITY) (PROVINCE)

PART B: CONTRIBUTIONS OR DONATIONS MADE IN CASH

DATE WHEN CASH RECEIPT NUMBER

NAME OF CANDIDATE AMOUNT OF
CONTRIBUTION WAS (Receipt issued by
(For whose benefit the contribution was made) CONTRIBUTION
MADE Candidate)

TOTAL CASH CONTRIBUTIONS OR DONATIONS MADE ₱ -

PART C: CONTRIBUTIONS OR DONATIONS MADE IN KIND

DATE WHEN IN-KIND
DESCRIPTION OF NAME OF CANDIDATE MARKET VALUE OF IN-
CONTRIBUTION WAS
IN-KIND (For whose benefit the contribution was made) KIND CONTRIBUTION
MADE

TOTAL IN-KIND CONTRIBUTIONS OR DONATIONS MADE ₱ -

PART D: CERTIFICATION AND OATH

The undersigned contributor, after being duly sworn, do hereby certify that: (1) the foregoing contributions were made by him/her to the candidates or their duly

authorized representatives; (2) that all the information provided and stated in this report are true and correct; and (3) that the contributions were made in

accordance with the pertinent provisions of the Omnibus Election Code, as amended, and other pertinent laws.
DATA PRIVACY ACT

The udersigned consents on the general use and sharing of information obtained in this disclosure and its attachments for legitimate and authorized purposes.
AFFIX SIGNATURE HERE


(SIGNATURE OVER PRINTED NAME) (DATE SIGNED)

SUBSCRIBED AND SWORN TO BEFORE ME this , affiant exhibiting his/her

issued by , with expiry date on

[Identification (ID) Type] [Serial No. of ID] [Government Agency issuing the ID]
.
[Expiry date of ID]

Document No.:
Page No.:
Book No.:
Series of 2023 .
(NOTARY PUBLIC SEAL & SIGNATURE)