Republic of the Philippines COMMISSION ON ELECTIONS Manila

ANNEX A1
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CERTIFICATE OF CANDIDACY FOR BARANGAY KAGAWAD

INSTRUCTIONS: (Read well before filling up this form.) 1. File personally or through your duly authorized representative, in THREE (3) LEGIBLE copies with the Office of the Election Officer in your city/municipality, during regular working hours starting October 11, 2013 @ 8:00 AM up to 5:00 PM of October 17, 2013 only. If filed through a representative, a written authority under oath must be presented. 2. Your certificate of candidacy will not be accepted by the Election Officer if you are not a registered voter in the barangay where you seek to be elected. 3. You must not file this certificate of candidacy if you have served for three (3) consecutive terms in the same office you seek to be re-elected. 4. Title such as Dr., Atty., Don, Ginoo, Senor, Datu, Hadji, Sultan, Bai, Senora, Kapitan or similar titles are expressly prohibited. 5. This certificate shall be sworn before a notary public or any official authorized to administer oath.

I hereby announce my candidacy for the position of Barangay Kagawad of Barangay_ , Municipality of , Province of on October 28, 2013 Barangay and Sangguniang Kabataan Elections; and after having been sworn to in accordance with law, hereby state the following:
1. MY NAME IS : 3. MY GENDER IS:
Male Female

4. MY AGE IS:

1.1 Last Name 1.2 First Name 1.3 Middle Name

2. I AM GENERALLY OR POPULARLY KNOWN BY THE NICKNAME OR STAGENAME : (Indicate only one nickname or stage name)

5. MY DATE OF BIRTH IS:

Month City / Mun. Province

Day

Year

6. MY PLACE OF BIRTH IS:

8. MY RESIDENCE/ ADDRESS IS:

8.2 City / Municipality

8.1 Province 8.3 Barangay

7. MY CIVIL STATUS IS:

Single Married Annulled / Divorced Widow/er
Legally Separated

8.4 House No./ Street / Subdivision

Full Name of Spouse, If Married

10. MY POST OFFICE ADDRESS FOR ELECTION PURPOSES IS: (Indicate if the same as No. 8)

9. MY PROFESSION OR OCCUPATION IS:

11. MY PERIOD OF RESIDENCE IN THE PHILIPPINES BEFORE OCTOBER 28, 2013 IS:
No. of Months No. of Years

12. I AM A REGISTERED VOTER OF:

Precinct Barangay City / Mun. Province

13. I AM A FILIPINO CITIZEN. 14. I AM A RESIDENT OF THE BARANGAY WHERE I SEEK TO BE ELECTED FOR AT LEAST ONE YEAR BEFORE THE BARANGAY ELECTION AND A REGISTERED VOTER THEREOF. 15. I AM NOT A PERMANENT RESIDENT OF, OR IMMIGRANT TO, A FOREIGN COUNTRY. 16. PRIOR TO THIS ELECTION, I WAS NOT ELECTED AND SERVED FOR THREE (3) CONSECUTIVE TERMS IN THE OFFICE I SEEK TO BE ELECTED. 17. I POSSESS ALL THE QUALIFICATIONS AND NONE OF THE DISQUALIFICATIONS FOR THE OFFICE I SEEK TO BE ELECTED TO. 18. I WILL SUPPORT AND DEFEND THE CONSTITUTION OF THE REPUBLIC OF THE PHILIPPINES AND WILL MAINTAIN TRUE FAITH AND ALLEGIANCE THERETO. I WILL OBEY THE LAWS, LEGAL ORDERS AND DECREES PROMULGATED BY THE DULY CONSTITUTED AUTHORITIES. I IMPOSE THIS OBLIGATION UPON MYSELF VOLUNTARILY, WITHOUT MENTAL RESERVATION OR PURPOSE OF EVASION. 19. I RECOGNIZE THE AUTHORITY OF THE ELECTION OFFICER NOT TO ACCEPT MY CERTIFICATE OF CANDIDACY IN CASE I AM NOT A REGISTERED VOTER IN THE BARANGAY WHERE I SEEK TO BE ELECTED.

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I hereby certify that the facts stated herein are true and correct of my own personal knowledge.

Signature of Candidate Above Printed Name

OATH SUBSCRIBED AND SWORN to before me this Identification Card No. Issued by: day of On: , 2013 at . , affiant exhibiting to me his/her

(Officer Authorized to Administer Oath)

(Affix documentary stamp) Doc. No. Page No. Book No. Series of 2013. _; _; _;