SWORN STATEMENT OF ACCOUNTABILITY OF THE PROPONENT

This is to certify that all the information and commitments in this COMPLIANCE
MONITORING REPORT for (indicate Semester Period ) for the
_______________________________(state name of project)______________________ are accurate and
complete to the best of our knowledge, and that an objective and thorough assessment of the
Project was undertaken in accordance with the dictates of professional and reasonable
judgment. Should I/we learn of any information which would make this COMPLIANCE
MONITORING REPORT inaccurate, I shall immediately bring the said information to the
attention of DENR-EMB.

I hereby certify that no DENR-EMB personnel was directly involved in the preparation of
this _________ (state name of project) _____ __
COMPLIANCE MONITORING REPORT other than to provide procedural and technical
advice consistent with the guidelines in the DAO 03-30 Revised Procedural Manual.

I hereby bind myself to answer any penalty that may be imposed arising from any
misrepresentation or failure to state material information in COMPLIANCE MONITORING
REPORT.

In witness whereof, I hereby set my hand this ___ day of __________

at ____________ ________________________ .

NAME OF PROPONENT HEAD

(Position)
(Company Name)

SUBSCRIBED AND SWORN TO before me this day of 20___, affiant

exhibiting his/her Community Tax Certificate No. _______________________________ issued
at ____________________ on .

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