AFFIDAVIT

I, ______________, of legal age, married, Filipino, and residing at _____________________________

after having been duly sworn in accordance with law, do hereby depose and state that:

That I am the Contractor of the project ___________________________________________.

That all bill of materials/labor/ furnishing in connection therewith have been fully paid by
me;
That I execute this affidavit for the purpose of collection payments due me from the
government with respect to the above said contract under Local Government Fund 2022.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of ___________, 2022 at
___________, Philippines.

_______________________________
(Affiant)

SUBSCRIBED AND SWORN to before me this ______ day of ___________, 2022 affiant
exhibiting to me his Community Tax Certificate No. ____________ issued on ___________________ at
Lucena City.

___________________________
NOTARY PUBLIC
TIN No. _______
Until December 31, 2022
Doc. _______ PTR No. _______
Page No. _______ Issued at ______
Book No. _______ Issued on _____
Series of 2022