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Annex'K-3"

CERTIFICATE OF CANDIDACY FOR Afflx Latest

MEMBER, SANGGUNIANG Photo Here

Passport Size
KABATAAN
ITISTRUCTIONS: (Phase re.d wellbefore filling-out the COC fo.m.)
l. Fill'out the items completely. Write N/A if Bn item is not applicabb,
Z. Print the COC Fom on BOTH SIDES (front and back) of a FOUO (8.5" x r3') or LEGAL (8.5'or r.4') saze copy paper.
l. Tldes such .s Or., Atty., Don, Ginoo, Sefior, Datu, Sultan, B.i, S.lora, X.pitan or other similar ddes are exprercly prohlbited.
1. This ce.tifi.ate shall be swom b.fore a notary public or any ofilclal .utho.ized to admihister o.th. Tte Electioh Orlicer may .dmihister the oath on the
COC5 filed within their area ofiurisdiction, free ot charge.
t. Flle lhis in TttREE (3) LEGIBLE copies with the COi4ELEC Ofllce concerned, on any day ftom Augun 28, 2023 (Monday) to September 2, 2023 (Satu.day), from
S|OO AM to 5:OO PH OtlLY.
t. No filing fe€ shall be imposed.
I
hereby announce my candidacy for the posilion ot MEUBE& SAIIGGUNIANG KABAIAAN of BARANGAY City/Municipality of
Province of in the Oatober 30, 2023 Bahngay and Sangguniang Kabataan (S() Eledions; and
after having been swoh to in accordaoce with law, I hereby state the following:

1. NAME: 17. SEX: 18, AGE ON ELECTION DAY:

I I
T
1.1 Last Name
_I
_T --T-l Years Monh/s
l-2 First Name
TT tt
I
I Day/s
Must be at lead eightEn (13) ycars
.ld but not lwe th.n tw.ntyjour

1.3 Middle Name

LI
2. NICKNAME OR STAGENAME:- (lndicate only one nicknam€ or stage
It|||lllIl name)
(24) vears oh on electi@ day. (Born
on od, 30, 1999 ro ocr. 30, 2005 to
p!$ the age requnement)

19. DATE OF BIRTHi

ru I

l4onth Day
3. RESIDENCE/ADDRESS:
3.1 Province ttttt 20. PLACE OF AIRTI|:

t[uI
3.2 City/f4un cipaliW

n-n [I
3.3 Barangay

III
City/l'lun.

Province

lIt
3.4 House No./ Street / Subdivision
21, CIVIL STATUS:
I

rl-t]-t Single !waow/er

l,larried
4, ADDRESS FOR ELECTION PURPOSES: (could be the same as No.3)
Full Na@ ot Spoue, il maried

22, PROFESSION OR OCCUPATION:

5. PERIOO OF RESIDENCE IN THE PHILIPPINES UP TO THE DAY BEFORE OCT. 30, 2023:
23. I AM A REGISTERED VOTER OF:
5.1 In the Philippines: tto. of vea.s fI No. of Months

[r]
I
Precinct

5.2 In the above-stated BararEay m.orv"urs[f No, of l'"lonths Barangay

City/Mun.
I AM A FIIJPINO CITIZEN,
Province
6.
7. I EX€CUTED A SWORN RENUNCIAT1ON OF fOREIGN CTTIZENSHIP. (IF APPLICqBE, ATTACH A COPY)
a. I AI.4 NOTA PERMANENT RESIDENT Of, OR AN II'4I'IIGRANT TO, A FORE]GN COUNTRY.
9. I AM A QUAUFIED VOTER OF THE KATIPUNAN NG KA&ATAAN OF TH€ ABOVE-STATEO BARANGAY.
24. OFFICIAL E-MAIL ADDRESS:
t0 I AM NOT RELATED WITHIN THE 2*O CVIL OEGREE OF CONSANGUINIT'Y OR AfFINITY TO ANY INCUMBENT ELECTEO (For notice and election purposes)
NAIIONAL OFFICIAL OR TO ANY INCI'M8ENT ELECIEO REGIONAI, PROVINCIAL, CITY, MUNICIPAT, OR BARANGAY OFFICIAL IN
IHE LOCALIW WHERE I SEEK TO 8E ELECTED TO.
11_ I HAVE NOi AEEN CONV'CTED BY FINAT OF Airy CRIME IIWOIVING IVIORAI TURPITUDE.
11. 'UDGMENT
I AIq EUGIBLE FOR THE OFFICE I SEE( TO 8E ELECTED TO.
25. Have you ever been found liable for an
I WIL]- FILE, WITH THE OFACES OF THE COMMISSION, WTTHIN THIRTY (30) DAYS AfTER ELECIION OAY, I"IY FULI- IRUE ANO
offense which canies with it the
13.
ITEMIZED sIAtEIqEtlT OF COI'IRIBUnONS ANO E(PENOTTURES (socE) IN CONNECTION wml THE ELECTION.
14 I WILL SUPPORT ANO DEFEND THE CONSTTN,TION OT THE REPIJEUC Of THE PHIIJPPIII€S AND WILL MA]NIA,IN TRUE FATIH accessory Penalty of perpetual
ANO ALIEGIANCE THTRETO. 1 WILI OBEY THE LAWs, LEGAT ORDERS, AND DECREES PROMUTGATED BY THE DULY disqualificatton to hold public omce,
CONSTrIUTED AUTHORITIES. I IMPOSE IHIS OALIGATION UPON MYSEtr VOLUNTARILY, WTTHOW TEMTAL REsERVATION OR which has become final and executory?
PIIRPOSE OF EVASION.
15 I SHALL NOT ADVOCATE VIOLENCE OR UNLAWFUL MEANS TO ACHIEV€ I'1Y GOATs. Yes (Please provide details at the
16 I GIVE CONSENT TO THE COIIIIISSION ON ELECTIONS TO COLLEgT, DISCTOSE OR SHARE, ANO PROCESS THE PERSONIJ. back)
DATA I PROVIDED HEREIN FOR ETECIION ANO OTHER LAWFUL PI]RPOSEs IN ACCORDANCE WITH THE PRIVACY NOTICE AT
TI]E BACK OF THIS FORM, AND AS MAY BE AUTHORIZEO 8Y EXISIING LAWS.

I hereby certify that the facts stated herein are true and correct to the best of my knowledqe

Sig..tu.e of Ca.didate over Pnrt.d ame

OATH
SUBSCRIBED AND SWORN to before me this day of 2023, at affiant exhibiting to me an
issued by on
Identiflcation documenvcard which contains a photograph and signature bearing No.
-
Doc. No.
Paoe No. ; (Nnr P3o.oo d€urun6ryn'mP)
(Officer Authorized to Administer Oath)
Book No, _; - -,
Series of 2023. -;
T}IIS FORM C{N OE PHOTOCOPIED OR RE'ROCUCEO AND TS AVAILABI"E AT THE COI1ELEC OFFICES FREE Of CHARGE
Ot MAY 8E DOW'i{tOAD€D FROH THE COI{ELEC OFFICIAL WEBSm (ww-dnele<.od,-oh)
 Case Docket
D o Gase Title Date
D Filedo Status

Name of the Substitute Spouse, if applicable

(in case of death of candidaA

The collected p€rsonal data will be encoded in trle information system developed by the Commission on Elections (COIeIELEC). The personal
data inputt€d in the inrormation system will be used by the COMELEC in fle preparation, posting and/or prrblication of th€ list of candidates
and other eledion{elated documents or forms.

For legrtimate research ne€ds and inquiri€s, and only for the purposes specilled in ahe r€quesL the COIYELEC may disdose and share your CoC
and/or its contents. tYoreover, the COI'IELEC may use and disclose your COC and/or its contents in any proceeding ol anvestigation in which
your COC aM/or its contents is/ar€ in issue or may find releva.ce.

Only authorized personnel are allowed to arcess and process your personal data. Immedaately after the election period or upon the expration
ofthe storage p€riod set in existing COI,IELEC rules and policies, and laws and regulations, whichever applies, the physicalaod digital copies of
yoor personal data wall be anonymized, deleted, and discarded following the disposition procedures of the COMELEC and the Nalional Archives
of the Philippines.

You have s]e nqht to ask for a copy of your COC o. any personal data it contains. Also, you may wathdraw yorrr candidacy in a.cordanc€ with
the coMELEc rules and policies on the matt€r.

If you have quedions regarding lhis Privacy Noticg pleas€ send an e.nail to dpo@cone/&-goyph.