REPUBLIC OF THE PHILIPPINES ANNEX “A”

CITY/ MUNICIPALITY OF ALFONSO, CAVITE

SWORN STATEMENT WITH UNDERTAKING

I, _____________________________________ of legal age, Filipino and a resident of

____________________________, Alfonso, Cavite, Philippines, after having been duly sworn to, in
accordance with law, do hereby depose and say, that:
1. I am a registered voter of ___________________________________________;
2. I was duly authorized by __________________________________ to claim and receive his/her
Voter’s Certification, as shown in the authorized letter hereto attached as ANNEX “A”;
3. I undertake to deliver the said Voter’s Certification immediately from its receipt to its rightful
owner, otherwise, I undertake to return said Certification to the Office of the Election Officer (OEO)
of Alfonso, Cavite, within seven (7) days from my receipt of the same;
4. I release the Election Officer and Election Assistant of the OEO of Alfonso, Cavite of any liability
should I lose the said Certification or should I fail to deliver the same to its rightful owner;
5. I fully understand that I will be liable for perjury, theft, estafa or any other criminal liability, as the
case maybe, should it be established that I am not the duly authorized representative to receive the
said Voter’s Certification, or that I failed to deliver the same to its rightful owner.

IN WITNESS HEREOF, I hereby affix my signature this ________ day of

______________________, 2017, in the City/ Municipality of Alfonso, Cavite, Philippines.

_______________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______ day of _______________________, 2017, in

the City/ Municipality of Alfonso, Cavite.

ALICIA TIBAYAN MOJICA

Election Officer III