REPUBLIC OF THE PHILIPPINES )

) S.S.

AFFIDAVIT

I, _________________________________________, Filipino, _____ years old, and with

address at ___________________________________________________________, after having
been duly sworn to in accordance with law, do hereby depose and state:

1. I am a registered voter for the 2019 National and Local Elections at Precinct No. _____,
Clustered Precinct _____________, Polling Place _________________________________,
District _____________, City of _____________, Province of _____________, as can be show
in the Election Day Computerized Voter’s List (EDCVL);

2. On 13 May 2019, at around ______ a.m. / p.m., I duly cast my vote for the 2019 National and
Local Elections at the above stated polling place.

3. At the time I cast my vote:

 Initially, the proceedings appeared to be in order. However, while waiting for the printing
of the voter’s receipt by the VCM, I noticed a discrepancy between the actual votes that I
casted and the votes that appeared in the voter’s receipt. Specifically, I voted
______(Name of Candidate)________ for ___(Position)___by fully shading the oval
beside his name in my ballot. Upon reading the voter’s receipt, the name of
_________________________ was indicated as my choice for ___(Position)___.

 I immediately called the attention of the BEI regarding this discrepancy and I was allowed
to register my objection by printing my name and affixing my signature on the voter’s
receipt, which I returned to the BEI.

 Despite calling the attention of the BEI to said discrepancy, they refused to register and
note my objection against the discrepancy.

 I was not allowed to print and sign my name on the voter’s receipt.

 The BEI tore the voter’s receipt, making it impossible for me to register my objection
against the discrepancy.

 After casting my vote, the following irregularities transpired:

________________________________________________________________________
________________________________________________________________________
_______________________________________________________________

4. I am executing this affidavit to attest to the truth of the foregoing statements, in support of my
protest against the fact that the voter’s receipt does not reflect the votes that I actually cast
during the 9 May 2016 elections and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereby set my hand this ______________________ at the

_____________________.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____________________ at

____________________________, affiant exhibiting to me his/her _______________ valid until
_______________.