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Supplementary Data Annex "E": PWD Personal Information
Supplementary Data Annex "E": PWD Personal Information
ph Annex "E"
SUPPLEMENTARY DATA
(Persons with disabilities/Senior Citizens with disabilities/ Indigenous People/Indigenous Cultural Communities)
BARANGAY: Non-Manifest
Comunication Assistance
Are you a member of any Indigenous People (IP) or
Indigenous Cultural Communities (ICC)? Accessible Precinct
Visual Assistance
Yes No None
If yes, please indicate the Name of IP/ICC community
PWD/SENIOR CITIZEN
Are you willing to Yes
vote in accessible
Name of IP/ICC Community polling place? No
Date:_________
Applicant's Left Thumbmark Applicant's Right Thumbmark
CERTIFICATION/ATTESTATION BY ASSISTOR
(For Illiterates/Persons with Disability/Indigenous People [IP] /Indigenous Cultural Communities [ICC])
I, ________________________________________________________________ , a resident of
_________________, whose name and signature appear below, hereby bind myself and declare
under oath:
IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of ______, 20___ at
________________________, Province of ___________________.
Election Officer
Signature over Printed Name
Downloaded from: http://www.comelec.gov.ph Annex "E"
SUPPLEMENTARY DATA
(Persons with disabilities/Senior Citizens with disabilities/ Indigenous People/Indigenous Cultural Communities)
BARANGAY: Non-Manifest
Comunication Assistance
Are you a member of any Indigenous People (IP) or
Indigenous Cultural Communities (ICC)? Accessible Precinct
Visual Assistance
Yes No None
If yes, please indicate the Name of IP/ICC community
PWD/SENIOR CITIZEN
Are you willing to Yes
vote in accessible
Name of IP/ICC Community polling place? No
Date:_________
Applicant's Left Thumbmark Applicant's Right Thumbmark
CERTIFICATION/ATTESTATION BY ASSISTOR
(For Illiterates/Persons with Disability/Indigenous People [IP] /Indigenous Cultural Communities [ICC])
I, ________________________________________________________________ , a resident of
_________________, whose name and signature appear below, hereby bind myself and declare
under oath:
IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of ______, 20___ at
________________________, Province of ___________________.
Election Officer
Signature over Printed Name
Downloaded from: http://www.comelec.gov.ph Annex "E"
SUPPLEMENTARY DATA
(Persons with disabilities/Senior Citizens with disabilities/ Indigenous People/Indigenous Cultural Communities)
BARANGAY: Non-Manifest
Comunication Assistance
Are you a member of any Indigenous People (IP) or
Indigenous Cultural Communities (ICC)? Accessible Precinct
Visual Assistance
Yes No None
If yes, please indicate the Name of IP/ICC community
PWD/SENIOR CITIZEN
Are you willing to Yes
vote in accessible
Name of IP/ICC Community polling place? No
Date:_________
Applicant's Left Thumbmark Applicant's Right Thumbmark
CERTIFICATION/ATTESTATION BY ASSISTOR
(For Illiterates/Persons with Disability/Indigenous People [IP] /Indigenous Cultural Communities [ICC])
I, ________________________________________________________________ , a resident of
_________________, whose name and signature appear below, hereby bind myself and declare
under oath:
IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of ______, 20___ at
________________________, Province of ___________________.
Election Officer
Signature over Printed Name