Republic of the Philippines

Commisison on Elections

14 MAY 2018 Synchronized Barangay and Sanguniang Kabataan Elections

STATEMENT OF CONTRIBUTIONS AND EXPENDITURES

NAME: _________________________________________ POSITION:______________

CELLPHONE NUMBER:

ADDRESS: ________________________________________ __________________

_________________________________________________ E-MAIL ADDRESS:

_______________________

A. CONTRIBUTIONS RECEIVED:
1. Total amount of contribution received: Php

B. EXPENDITURES INCURRED:
1. From personal cash: Php
2. From contributions received: Php
________________________

TOTAL EXPENDITURES INCURRED: Php

ACKNOWLEDGMENT

I, ___________________________________________, after being duly sworn to, hereby depose and

state that:

(1) This Statement and its attached Annexes are supported by receipts, vouchers, and other
documents reflecting the full, true, accurate and complete election contributions received and
expenditures incurred by me and / or by my duly authorized representative;
(2) The expenditures incurred by me are lawful purpose and the contributions were not received from
persons or entities prohibited by law to give contributions.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___________ day of _____ 2018.

(Name and Signature of Candidate)

Subscribed and sworn TO BEFORE ME THIS _________ day of ________________2018,

candidate exhibiting his/her ________________________________ with number
_______________________ issued by ________________________________________________ with
expiry date_____________________________.

ADMINISTERING OFFICER