STATEMENT OF ELECTION CONTRIBUTIONS AND EXPENDITURES
________________________Date of Election
Full Name of Candidate:
_____________________________________
Post Office Address of Candidate:
_____________________________________
Office for which Filer is a Candidate:
_____________________________________Period Covered:From
_______________ to _______________
CONTRIBUTION RECEIVED:(Attached Schedule 1 for itemized
contributions)Total contribution from other
persons.................................................. P
_____________TOTAL CONTRIBUTIONS
RECEIVED...................................................................
P ___________ __ EXPENDITURES INCURRED:(Attached Schedule 2 for
itemized expenditures)Total expenditures paid by candidate out
ofPersonal
funds.........................................................................
P __________ ____Total expenditures paid of contributions
Received...................................................................................
P ______________
TOTAL EXPENDITURES
INCURRED..................................................................
P ______________
REPUBLIC OF THE PHILIPPINES)
_________________________),
I ____________________________________, after being duly sworn,
hereby depose and say:That the foregoing statement and supporting
schedules (Schedule 1 & 2) are supported by receipts, vouchers
and other documents reflecting the full, true, accurate and
complete election contributions received and expenditures incurred
by me and/or by my duly authorized representative during the period
indicated:That the expenditures incurred are for lawful purposes
and the contributions were not received from persons or entities by
law to give contributions.IN WITNESS WHEREOF, I have affixed my
signature this ____ day of __________, 2015.
__________________________ (Signature of Candidate)
SUBSCRIBED AND SWORN to before me this ______ day of __
_______________, 2015 in _______________________ affiant exhibiting
his/her Community Tax Certificate No. _____________, issued on
_______________, 2015 at ____________________________.
__________________________Notary Public Doc. No. ________Page
No. ________Book No. ________Series of ________ANNEX C-1
