Republic of the Philippines

Province of Northern Samar

Municipality of Catarman

S.S.
AFFIDAVIT

I, ________, of legal age, single/married, Filipino citizen, with

residence address at _______________, under oath, depose and state
that:
1. I was elected as a member of the Sangguniang Barangay of the
barangay government of ______________ for one term or from
December 1, 2010 and until November 30, 2013;
2. To the best of my knowledge and based on authentic records, I was
not employed in the government whatsoever during my
tenure/term as member of the Sangguniang Barangay for one term
or from December 1, 2010 and until November 30, 2013 in the
government, GOCCs or in any government instrumentality and I
did not receive any salary/compensation except my honorarium;
3. I can attest each and every fact mentioned in this affidavit before
any proceedings and that I shall be held liable for whatever falsity;
4. I am executing this Affidavit to attest to the veracity of the
foregoing facts and for the purpose of complying with the
requirements of barangay eligibility.
IN WITNESS WHEREOF, I hereunto affix my signature this 5th
day of October 2015 at Catarman, Northern Samar.
________
Affiant
Proof of Identity: ________
SUBSCRIBED AND SWORN to before me this 5th day of October
2015 at Catarman, Northern Samar, affiant exhibiting to me competent
proof of identity, the details of which is shown below affiants name.
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 2015.