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AFFIDAVIT OF PAYMENT OF CLAIMS

AND
CERTIFICATION OF MATERIALS

By: XYZ CONSTRUCTION Contract No. ______________________


Contractor
Address: 123 Sampaguita St., Tacloban City

This ______ day of ___________________, 2018 affiant personally appeared before


me, a Notary Public, being by me first duly sworn/affirmed, states that all materials meet
or exceed the specifications of the Contract and that all suppliers of labor and materials
have been paid all sums due them for work performed or materials furnished in the
performance of the Contract between the City of Tacloban, Leyte, Owner, and XYZ
Construction, Contractor, dated ______________________, 2018,for the construction of
_______________________________ project or arrangements have been made by the
Contractor satisfactory to such suppliers with respect of payment of such sums as may
be due them by the Contractor.

By: Mr. Cardo Dalisay


Contractor/Proprietor
XYZ CONSTRUCTION

SUBSCRIBED AND SWORN TO before me this _____ day of ________, 2018 in


___________, Affiant Exhibiting to me his __________________ issued on
______________________ in______________________ , Philippines.

Doc No. : __________


Page No. : _________
Book No. : _________
Series of 2018.

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