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Republic of the Philippines

ANNEX A
Commission on Elections

14 MAY 2018 Synchronized Barangay and Sangguniang Kabataan Elections

STATEMENT OF CONTRIBUTIONS RECEIVED


DATE NAME OF CONTRIBUTOR ADDRESS NATURE OF AMOUNT
RECEIVED CONTRIBUTION
(CASH / IN-KIND)

TOTAL CONTRIBUTIONS RECEIVED Php


CERTIFICATION
I hereby certify that: (1) the contributions listed above were made to me as a SUBSCRIBED AND SWORN to before me this _______ day of
________________2018, candidate exhibiting his/her __________________________with
candidate; (2) all entries specified above are true and correct; (3) they are supported by number ________________ issued by ____________________________________ with expiry
official receipts issued by me upon acceptance; and (4) the contributions are from sources date __________________________.
not prohibited by laws.

______________________________________ ADMINISTERING OFFICER


(Full Name & Signature)

______________________________
(Date Filed)

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