COMMISSION ON ELECTIONS

FORM
October 30, 2023
Barangay and Sangguniang Kabataan Elections 1
Statement of Contributions and Expenditures

PART I: PERSONAL INFORMATION OF THE CANDIDATE

1 MENDOZA MAE ANN VALDEZ
NAME OF CANDIDATE: (SURNAME) (FIRST NAME) (MIDDLE NAME)
GENDER: FEMALE
(EXTENSION)
2 ELECTIVE POSITION: CHAIRPERSON, SK
3 CONSTITUENCY OF THE ELECTIVE POSITION:
BACSIL SAN FERNANDO LA UNION 1
(BARANGAY) (CITY/MUNICIPALITY) (PROVINCE (REGION)

PART II: TOTAL ELECTION CONTRIBUTION AND EXPENDITURE

II. A. CONTRIBUTIONS RECEIVED (Itemized entries in the schedule of contributions, indicate "0.00" if none received)
1 CASH CONTRIBUTIONS RECEIVED FROM OTHER SOURCES: ₱0.00
2 IN-KIND CONTRIBUTIONS RECEIVED FROM OTHER SOURCES: ₱0.00
TOTAL CONTRIBUTIONS RECEIVED ₱0.00
II. B. EXPENDITURES (Itemized entries in the schedule of expenditures, indicate "0.00" if none received)
1 EXPENDITURES PAID OUT OF PERSONAL FUNDS / RESOURCES: ₱180.00
2 EXPENDITURES PAID OUT OF CASH CONTRIBUTIONS: ₱0.00
3 EXPENDITURES INCURRED USING IN-KIND CONTRIBUTIONS: ₱0.00
TOTAL EXPENDITURES INCCURED ₱180.00

PART III. SUMMARY REPORT OF LAWFUL EXPENDITURES

III. A : SUBTOTAL OF LAWFUL EXPENDITURES PER EXPENSE TYPE/CATEGORY
Travel expenses of candidate and campaign personnel during the campaign and incidental personal ₱0.00
A expenses
Compensation of campaigners, clerks, stenographers, messengers, and other persons employed in the ₱0.00
B campaign
Telephone, mobile phone usage fees, prepaid phone load, internet access, postages, freight and ₱0.00
C courier charges
₱180.00
Stationery, printing and distribution of printed materials relative to candidacy;
D
₱0.00
Employment of watchers at the polls
E
₱0.00
Rent, maintenance and furnishing of campaign headquarters, office or place of meetings
F
Political meetings and rallies & the use of sound systems, lights and decorations during said meetings ₱0.00
G and rallies
Newspaper, radio, TV and other advertisements to promote the candidacy, including
₱0.00
H website/internet ad placements
SUB- TOTAL (Item A to H) ₱180.00
III. B : EXPENDITURES INCURRED (Itemized entries in Schedule of Expenditures)
Employment of counsel
I ₱0.00
Copying and classifying lists of voters, investigating and challenging the right to vote of persons
J registered in the lists ₱0.00
Printing of sample ballots in such color, size and maximum number as may be authorized by the
K Commission ₱0.00
SUB-TOTAL (Item I to K) ₱0.00
TOTAL EXPENDITURES INCURRED ₱180.00

MAE ANN V. MENDOZA NOVEMBER 13, 2023

NAME AND SIGNATURE DATE SIGNED

THIS
Indicate "✓" beside form SECTION IS FOR
code/document COMELEC
name USE ONLY
if submitted, "✗" if - DO NOT ENCODE / WRITING ANYTHING BEYOND THIS LINE
not.
☐ FORM 1 ☐ Contribution Receipts
☐ FORM 2 ☐ Expenditure Receipts
☐ FORM 3 ☐ Obligations Payable
☐ Others: pls. specify: NO. OF PAGES: _________
(This space is for the receiving date/time stamp of the receiving office)

Page 1 of 3
 COMMISSION ON ELECTION FORM
October 30, 2023

SCHEDULE OF ELECTION CONTRIBUTION AND EXPENDITURES

Barangay and Sangguniang Kabataan Elections 2
NAME OF CANDIDATE: MENDOZA MAE ANN VALDEZ
(SURNAME) (FIRST NAME) (MIDDLE NAME) (EXT)

Type of Contribution
Schedule of Contributions Received
DESCRIPTION
DATE RECEIVED RECEIPT NUMBER FULL NAME OF CONTRIBUTOR ADDRESS OF CONTRIBUTOR AMOUNT/VALUE OF CONTRIBUTION
(for in-kind contributions)

N/A N/A N/A N/A N/A N/A ₱0.00

(Cash or In-kind)

TOTAL CONTRIBUTIONS RECEIVED ₱0.00

Schedule of Expenditures
RECEIPT/ INVOICE FULL NAME OF BUSINESS FIRM OR ADDRESS OF BUSINESS FIRM TIN OF CONTRACTOR or BUSINESS Exp Type AMOUNT/VALUE OF
DATE INCURRED DESCRIPTION OF EXPENSE
NUMBER CONTRACTOR OR CONTRACTOR FIRM (A-K) EXPENDITURE

Sia Bldg. Quezon Ave. Brgy. 1 San Fernando City,

October 23, 2023 2894 TARP MO PRINT KO ATBP. 933-103-204-00000
La Union 2x2 (3) ₱180.00

TOTAL EXPENDITURES INCURRED ₱180.00

Schedule of Unpaid Obligations

DESCRIPTION OF THE OBLIGATION

PURPOSE REMAINING OBLIGATION AMOUNT/VALUE OF

DATE INCURRED CONTRACT / LOAN NO. NAME OF CREDITOR ADDRESS OF CREDITOR
(for incurring obligations) (partial payments were made) OBLIGATION

N/A N/A N/A N/A (i.e.

N/A loan, etc.) N/A N/A ₱0.00

TOTAL UNPAID OBLIGATIONS ₱0.00

.

MAE ANN V. MENDOZA NOVEMBER 13, 2023

NAME AND SIGNATURE DATE SIGNED

NOTE: Use additional sheet/s if necessary
 COMMISSION ON ELECTIONS
October 30, 2023 FORM
Barangay and Sangguniang Kabataan Elections
3
CERTIFICATION AND CONSENT ON DATA PRIVACY
The undersigned candidate, after being duly sworn to, hereby depose and state that:

(1) The contributions listed in Form 1,2 and other supporting were made to me as a candidate and it was received by me and/or my duly authorized representative;

(2) The expenses listed in Form 1, 2 and other supporting documents were incurred by me as a candidate or by my duly authorized representative/s;
(3) The obligations listed in Form 2 were incurred by me as a candidate or with my authority by my duly authorized representative
(4) This disclosure and its attachments, are supported by receipts, vouchers, and other documents reflecting the full, true, accurate, and complete contributions received and expenditures
incurred by the undersigned candidate and my duly authorized representative;
(5) The contributions received and expenditures incurred are in accordance with the campaign finance laws and regulations;
(6) I consents on the general use and sharing of information obtained in my report and supporting documents for legitimate purposes; and
(7) All entries specified on my report on Election Contributions and Expenditures and supporting documents are true and correct.

IN WITNESS WHEREOF, the undersigned hereunto affix his/her signature on [date signed].

AFFIX SIGNATURE HERE  MAE ANN V. MENDOZA

NAME AND SIGNATURE

JURAT

SUBSCRIBED AND SWORN TO before me on date notarized , affiant exhibiting his/her

issued by expiring on [date of expiry].
(Type of identification document) (ID Number) (Government Agency issuing the ID)

Doc. No.:
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