ATTESTATION FORM OF CHD/FICT/MST VALIDATORS

I, _____________________ [Full Name of Validator], _____________ [Position], a duly

authorized representative of ___________________, [CHD/FICT/MST] do hereby declare and
attest to the following:

1. That the submission of ________________ [Name of Facility] in ___________________

[Region] had undergone thorough verification and validation by the management of this
facility as manifested in their attestation form.

2. That this submission through the Health Emergency Allowance Processing System
(HEAPS) had been validated based solely on the information made available by the facility
and guided by the provisions of Republic Act No. 11712 (Public Health Emergency
Benefits and Allowance for Health Care Workers Act), its implementing rules and
regulations and supplemental guidelines. Should the actual facts be different from the
information contained in the submitted CREC report to which this CHD/FICT/MST is not
in position or no capacity to verify, the facility shall bear sole responsibility therewith.

3. That proper exercise of diligence had been observed in the validation of this submission
and in consideration of the presumption of regularity.

Done this ___ day of _______________, 2022 in __________________.

By:

……………………………

[SIGNATURE OVER FULL NAME OF VALIDATOR]

[Position]