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Republic of the Philippines) S.S.

AFFIDAVIT OF INDEPENDENCE

I, ________________, of legal age, married, Filipino, with office address at


_______________, Philippines, after being duly sworn to in accordance with law, hereby
depose and state:

1. That I am a Certified Public Account since _________ with PRC No. ____________;

2. That I am a partner in _______, a Philippine professional partnership and a member of


______________________;

3. That _______________ has contacted __________________, inquiring about hiring our


services for purposes of commissioning as Independent Certified Public Account (CPA)
to perform actual examination, verification evaluation and audit of voluminous
documentary evidence of the former in their tax refund case pending before the
_______________ Division of the Court of Tax Appeals (CTA) with CTA Case No.
_________ for the refund/issuance of tax credit for erroneously paid income taxes in the
following amounts:

a. XXXXX for calendar year 2013, and

b. YYYYY for calendar year 2014.

4. That ____________ and its parent company, ____________ were and are neither the
client of ________ or of _____________ nor my personal client for any service related to
the exercise of profession as CPA;

5. That I warrant my independence as well as that of ___________ from


________________ and ________________;

6. That I am executing this Affidavit for purposes of commissioning as Independent CPA for
the tax refund case of ____________.

IN WITNESS WHEREOF, I have hereunto set my hand this _________________


at ______________________, Philippines.

_______________
Affiant

SUBSCRIBED AND SWORN TO before me this __________________ at


_____________________, affiant exhibiting to me his competent evidence of identity by
way of ____________________________ issued at _______________________ on
_________________ and valid until _________________.

Doc. No. ____;


Page No. ____;
Book No. ____;
Series of 2016.

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