VER|FTED L|ST OF HEADS OF PROVINCIAL, Ctry AND

MUNICIPAL CHAPTERS WITH RESPECTTVE ADDRESSES

t, of legal age, single, Filipino, and a

resident of being the duly authorized representative of
hereby submits the following list:

NAMES OF HEAD PROVINCIAL CHAPTER ADDRESS

1.
2.

NAMES OF HEAD CITY CHAPTER ADDRESS

l"
2

NAMES OF HEAD MUNICIPAL CHAPTER ADDRESS

1.
2.

lN WITNESS WHEREOE I have hereunto affixed my signature this in

BARMM.

( signatu re of representative)
NAME OF REPRESENTATIVE

I hereby certify that the facts stated herein are true and correct of my own perconal knowledge.

President/Chalrman/S€cretary General

ATTESTATION

t, the of
of legal age, and with Postal address
after having duly sworn to in accordance with laq hereby
and state that:

t. I am one of the officers of the authorized to verifY the

foregoing M o n ifestotio n ;
2. I have caused the foregoing Monifestotion to be prepared and filed with the Commission on
Elections; and
3. I have read a nd un derstood the contents thereof and acknowledge that the same a re tru e and
correct based on my personal knowledge.

President/Chairman/Secretary General

lN WITNESSWHEREOF, I have hereunto affixed mysignaturethis affiant

me his/her CTC/ ldentification Card No.
, issued by: on:

NOTARY PUBLIC

No. ;

No. ;
No. ;