Name of the Procuring Entity Project Reference Number

Name of the Project

Location of the Project

Standard Form Number: SF-GOOD-12

Revised on: May 24, 2004

AFFIDAVIT OF DISCLOSURE OF NO RELATIONSHIP

I, ______________________, of legal age, __(civil status)__, residing at

____________ ____________________ after being sworn in accordance with law, do hereby
depose and say:

1. That I am the authorized representative of __(Name of Bidder)__ with office address

at ___(Address of Bidder)____;

2. That the firm/partnership/joint venture/corporation, or any of its officers, directors ,

controlling stockholders and members, I represent for the bidding of ____(Name of
Project)_____, is not related by consanguinity or affinity up to the third civil degree to
the head of agency, to the BAC, TWG or Secretariat members, or to any Procuring
Entity official, who directly or indirectly took part in the bidding process;

3. That I am making this statement in compliance with Section 47 of the Implementing

Rules and Regulations of Republic Act No. 9184, and in accordance with the
requirements of the ___(Procuring Entity)___-BAC.

IN WITNESS WHEREOF, I have hereunto set my hand this _________________ day of

__________________, 20__, in the City of __________________, Philippines.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________________________ day of

_____________________, Philippines.

___________________
Notary Public

Doc. No. __________;

Page No. __________;
Book No. __________;
Series of 20__

One of the legal documents required to be in the Eligibility Envelope of a prospective bidder is its Sworn
affidavit that it is not related to the head of procuring entity, members of the BAC, TWG and Secretariat
and members of the PMO, and the designers of the project, by consanguinity or affinity up to the third
civil degree.