Republic of the Philippines )

Municipality of San Jose de Buenavista )S.S

Province of Antique )
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AFFIDAVIT

I, _________________________, Filipino, of legal age, single, and a resident of after having

been duly sworn to in accordance with law, do hereby depose and say:

That I am not related by consanguinity or affinity to the appointing or recommending

authority, or to the bureau or office or to the person who has immediate supervision over me in
the office, bureau or department of the Government where I will be assigned or appointed within
the prohibited degree of relationship under the law;

That I am not directly or indirectly interested financially in any contract with or any
franchise or special privilege granted by the Government or any of its subdivision, agency,
department or instrumentality including Government Owned or Controlled Corporation or its
subsidiary or otherwise derive pecuniary benefit where I may be called upon to act on account of
my office;

That I do not have any pending case(s) with the office, bureau, agency or department of
the Government where I will be assigned or appointed;

That I execute this affidavit to attest to the truth of the foregoing.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 3rd day of October in the
Municipality of San Jose de Buenavista, Antique, Philippines.

_____________________________________
Affiant

SUBCRIBED AND SWORN TO before me this 3rd day of October, 2017 in San Jose de
Buenavista, Antique, Philippines, affiant being personally known to me with Attorney Roll Number
_______ as competent proof of her identity.

WITNESS MY HAND AND SEAL this 3rd day of October, 2017 in San Jose de Buenavista,
Antique, Philippines.