Republic of the Philippines

City of Balanga, Bataan, S.S.

SWORN STATEMENT
I _______________________________, of legal age, single/married,
with postal address at___________________________, after having duly
sworn in accordance with law hereby depose and state:

That I am presently employed with the DepEd. as

_______________________;

That I have been employed in __________________________________

Name of School
since _____________________or for a period of _______________;

That I was designated as coach of _______________________, who

will participate in the _____________________________________________-.

That all the athletes are not members of the National Team,
National Training Pool and Development Pool receiving monthly
stipend/allowance from the Philippine Sports Commission (PSC);

That all the athletes records submitted are true and correct to
the best of my personal knowledge;

That all the athletes of _____________, who will participate in the

_____________________________________ are eligible;

That I execute this Affidavit to attest to the authenticity and

veracity of all the documents submitted.

IN WITNESS WHEREOF, I have hereunto set my hand this

_______ day of _____________________, __________ in
___________________________, Philippines.

__________________
Affiant

SUBSCRIBED AND SWORN TO before me this ______day of

__________________ in ____________________________ affiant exhibiting to
me his/her Government issued ID/SSS/PRC / Phil health, etc.
______________________.

PILAR C. IGNACIO
Administrative Officer V

FOR PALARONG PAMBANSA ONLY