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Republic of the Philippines

DEPARTMENT OF EDUCATION
REGION VI- WESTERN VISAYAS
DIVISION OF NEGROS OCCIDENTAL
Cottage Road, Bacolod City

SWORN STATEMENT

I hereby certify under oath that I have been actually enrolled in the schools
listed in the accompanying transcript of records and that have actually earned the
units therein. As required, the Bureau of Private Schools has been furnished with
authentic copies of the sworn statement and its closure.

KIMBERLY E. LOPEZ
Teacher I

SUBSCRIBED AND SWORN to before me this __________ day of ____________,


2023 at ____________________________________. Affiant exhibiting his/her Residence
Certificate No. _____________. Issued at __________________________ on
____________________, 2023.

___________________________________
(Signature of Person Administering Oath)

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