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COMMISSION ON ELECTIONS Form ARC

AUTHORITY TO RECEIVE CONTRIBUTIONS


Date filed: For the 09 May 2016 National and Local Elections

The undersigned candidate/party treasurer hereby grants the authority to his/her agent,
, ,
(SURNAME) (FIRST NAME) (MIDDLE NAME)
to receive contributions and issue receipts for the same on behalf of the candidate or party,
with the understanding and undertaking that the undersigned shall be responsible for the
actions of the said agent.

AFFIX SIGNATURE HERE RANDY CUENO CALAYCO


[NAME OF CANDIDATE]
Date signed: May 27, 2016
PARTY INFORMATION: Accomplish this part only if you are the party treasurer
NAME of PARTY
TREASURER: (SURNAME) (FIRST NAME) (MIDDLE NAME)
NAME OF
PARTY: (COMPLETE NAME OF PARTY) (ACRONYM)
PARTY Political Party Contact information:
TYPE: Party-List Group (Phone no. & e-mail address)
CANDIDATE INFORMATION: Accomplish this part only if you are a candidate)
NAME OF Calayco Randy Cueno
CANDIDATE: (SURNAME) (FIRST NAME) (MIDDLE NAME)
Elective District,
office Municipality/city/province of
sought: Vice Mayor elective office: President Roxas
Name of Contact information:
party: UNA (Phone no. & e-mail address)

AGENT INFORMATION: (Person authorized to receive contributions, whose name appears in main body)
Home/Office
Address:
Telephone &
E-mail Address:
Mobile No.:

ACKNOWLEDGMENT
REPUBLIC OF THE PHILIPPINES
City/Municipality of President Roxas

BEFORE ME, on _____ and in __________ , personally appeared the following persons
with competent evidence of their identity:
Expiry Issuing
Name Doc. Type ID No. Date Authority

Said persons acknowledged under oath to me under penalty of law, that the whole contents of this
document are true and the same are their free and voluntary acts and deeds.

WITNESS MY HAND AND NOTARIAL SEAL.

Doc. No.: NOTARY PUBLIC


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