OMNIBUS SWORN STATEMENT

REPUBLIC OF THE PHILIPPINES )

______________________________) ss

AFFIDAVIT

I, ________________, of legal age, single/married, Filipino, and residing at

_____________________________, after having been duly sworn in accordance with
law, do hereby depose and state that:

1. I am the duly authorized designated representative of

____________________________, with office address at
_____________________________________;

2. I am granted full power and authority to do, execute and perform any and all acts
necessary and/or to represent ___________________________________, the
bidding as shown in the attached duly notarized Secretarys Certificate issued by
the Corporation;

3. _________________________________________________, is not blacklisted

or barred from bidding by the Government of the Philippines or any of its
agencies, offices, corporation, or Local Government Units, foreign
government/foreign or international financing institution whose blacklisting rules
have been recognized by the Government Procurement Policy Board;

4. Each of the documents submitted in satisfaction of the bidding requirement is an

authentic copy of the original, complete, and all statements and information
provided therein are true and correct;

5. ____________________________________________, is authorizing the Head of

Procuring Unit or its duly authorized representative(s) to verify all the documents
submitted;

6. None of the officers, directors and controlling stockholders of

____________________ is related to the members of the Bids and Awards
Committee (BAC), the Technical Working Group, and the BAC Secretariat, the
head of the Project Management Office or the end-user unit, and the project
consultants by consanguinity or affinity up to the third civil degree;

7. ___________________________________ complies with existing labor laws and

standards; and

8. ___________________________________ is aware of and has undertaken the

following responsibilities as a Bidder:

1. It has taken steps to carefully examine all the bidding documents;

2. It has full knowledge of all conditions, local or otherwise, affecting the

implementation of the contract;

3. It has made an estimate of the facilities available and needed for the contract
to be bid, if any;

4. It has complied with its responsibility to inquire or secure Supplemental/Bid

Bulletins that may be issued by the BAC;
 5. It has determined and satisfied itself as to the a) location and nature; b) other
factors that may affect the cost, duration and execution of the contract;

9. _________________ did not give or pay directly or indirectly, any commission,

amount, fee, or any form of consideration, pecuniary or otherwise, to any person
or official, personnel or representative of the government in relation to any
procurement project or activity.

IN WITNESS WHEREOF, I hereby affix my signature this ____ day of _________ 2014
at _________________________, Philippines.

AFFIANT

SUBSCRIBED AND SWORN to before me this ____ day of ________ at

______________, Affiant having exhibited to me his Community Tax Certificate No.
__________ issued at ___________ on ___________.

NOTARY PUBLIC
Doc. No. ____;
Page No. ____;
Book No. ___ ;
Series of ____ .