Annex “A”

SWORN STATEMENT

REPUBLIC OF THE PHILIPPINES

PROVINCE OF_____________
CITY/MUNICIPALITY OF __________

I, (Name of Authorized User/Representative), (Nationality), of legal age designated as (Position) of (Registered

Name of Company/Corporation), with business address located at _____________________________________,
do hereby certify the following:

 THAT the company is engaged in, (line of business) and existing under (business name), with
TIN__________________.

 THAT the POS/BOS, Orpak Systor v.3.66 conform to the conditions/specification requirements set by
the Bureau of Internal Revenue;

 THAT the POS/BOS, Orpak Systor v.3.66 has the following essential features;

 User-friendly design
 Sale of both dry and wet stock from the main screen
 Graphical User interface designed for maximum cashier throughput intuitive
 Training a new cashier takes less than one hour
 Customized keyboard or touch screen uses icons for fast moving products
 Online wet and dry inventory status on the POS
 Max accumulating sales capacity is unlimited max digit of 10.

 THAT in the event that the foregoing be discovered to be in violation of existing rules and regulations,
I hereby undertake to face any legal sanctions and pay corresponding penalties thereof as provided
for under the National Internal Revenue Code of 1997;

I HEREBY DECLARE UNDER PENALTIES OF PERJURY THAT THE FOREGOING ATTESTATIONS ARE TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE.

Name and Signature of

Affiant/Authorized Representative
TIN: ___________________________

SUBSCRIBED and sworn to before me, in the City/Municipality of ____________________________, this day
of __________, 20___ by ____________________ with Residence Certificate No. _______ issued at
_____________ on, ______________ 20___.

Doc No.:
Page No.:
Book No.:
Series of 2022.

Republic of the
Philippines)