COMMISSION ON ELECTIONS FORM

October 30, 2023 Barangay and Sangguniang Kabataan Elections ROC

Omnibus Report of Contributions
(For Domestic Corporations)

PART A: PERSONAL INFORMATION OF THE CONTRIBUTOR

NAME OF
CORPORATION:
NAME OF THEAUTHORIZED
REPRESENTATIVE:
(SURNAME) (FIRST NAME) (MIDDLE NAME) (EXT)

CONTACT DETAILS: Mobile/Phone Nos.:

E-Mail Address:

BUSINESS 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 KIND
CONTRIBUTION WAS
IN-KIND (For whose benefit the contribution was made) CONTRIBUTION
MADE

TOTAL IN-KIND CONTRIBUTIONS OR DONATIONS MADE ₱ -

PART D: CERTIFICATION AND OATH

The undersigned authorized representative of the contributor, after being duly sworn, do hereby certify that the foregoing contributions were made by (Name of
Corporation) to the candidates or their duly authorized representatives; that all the information provided and stated in this report are true and correct; and that the
contributions were made in accordance with the pertinent provisions of the Omnibus Election Code and other pertinent laws, ; that the undersigned consents on the
general use and sharing of information obtained in this disclosure and its attachments for legitimate and authorized purposes.
DATA PRIVACY ACT

The udersigned consents on the general use and sharing of information obtained in this disclosure and its attachments for legitimate 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)