REPUBLIC OF THE PHILIPPINES

CITY OF ORMOC

AFFIDAVIT OF UNDERTAKING

I Mr./Ms. _________________________________ a resident of Sitio/Barangay

____________________ in the Municipality/City of _______________________ Province of
Leyte, recognizes the need of electricity in my house/building.

That our house is situated _______ meters from the service pole of LEYECO V.

That I am petitioning LEYECO V to approve my application despite of its excessive distance

with the following conditions and commitments:

1. I shall negotiate and secure the right of way on the areas or premises traversed by the line
from the tapping pole to my house/building.
2. I shall provide all the materials including the specified poles (in every 50 meters) for the
installation of the said line which shall not exceed Five Hundred (500) meters in length.
3. I shall provide a specified pole for every fifty (50) meters of line.
4. My kwh meter shall be installed within the fifty (50) meters from the tapping pole and be
provided with a Main Safety Switch or Circuit Breaker.
5. I am fully informed and aware of the possible low voltage and electrical hazard in the area as
a result of very lengthy line.
6. I shall be responsible in maintaining the line from the service delivery point (kwh-meter) up to
my household/building as well as keeping it safe from persons and property. And I shall bind
to exempt LEYECO V from whatever damages or losses it may incur.
7. I shall bind my self to all duly promulgated rules, regulations and policies instituted by Leyte
V Electric Cooperative, Inc. and other related and other government instrumentalities.
8. Any violation of the above conditions would mean rejection of my application and/or shall be
a cause for disconnection within forty-eight (48) hours from receipt of notice.

IN WITNESS WHEREOF, I have hereunto set my hands this _____day of_______________

2018 at ____________________________________________

______________________________
AFFIANT
Comm. Tax Cert. No._____________
Issued at: _____________________
On _______________________

SUBSCRIBED AND SWORN TO before me this _____ day of _______________ 2018 at the
City of Ormoc, Philippines. Affiant exhibited to me his/her Community Tax Certificate indicated
below his/her name.

Doc No______________
Page No_____________
Book No_____________
Series No____________
LOCATION OF RESIDENCE:
MAP/SKETCH:

RECOMMENDED SERVICE POLE INSTALLATIONFOR LINES THAT EXCEEDS MORE THAN 50 METERS OR LINES
THAT WITHIN 50 METERS BUT CROSSES A ROAD OR GO ACROSS THE NEIGHBORS ROOF OR PREMISES: