SEC Building, EDSA, Greenhills, Mandaluyong Cit:1...TO RepublicofthePhilippines Department ofFinance Securities andExchange Commission SEC Building, EDSA, Greenhills, Mandaluyong Cit:1

TO

Republic ofthe PhilippinesDepartment of Finance

Securities and Exchange CommissionSEC Building, EDSA, Greenhills, Mandaluyong Cit:1

NOTICE

ALL FOUNDATIONS

SUBJECT GUIDELINES IN THE ACCOMPLISHMENT AND SUBMISSION OFSWORN STATEMENT OF SOURCES, AMOUNT AND APPLICATION OFFUND (SS) AND CERTIFICATE OF EXISTENCE OF PROGRAM/ACTIVITY(COEP)

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Notice is hereby given that on 18 April 2013, the Commission En Bane approved thefollowing guidelines in the accomplishment and submission by "foundations of the SwornStatement by the President and Treasurer of the Sources, Amount and Application ofFunds and Program/Activity Planned, Ongoing and Accomplish,ed (SS) and Certificate ofExistence of Program/Activity (COEP):

1. COEP shall be issued by the Office of the Mayor, thE~Office of the BarangayChairman, or the national or local office of either the Department of Social Welfareand Development (DSWD) or the Department of Health (DOH), relative to thespecific program/activity of the foundation on the locality on which suchgovernment office exercises jurisdiction;

2. COEP issued by Heads/Officers of private institution or actualbeneficiaries/recipients of the program/activity shall be allowed in lieu of COEPissued by the government offices/entities specified in item 1 above: Provided, ThatCOEPissued by such private persons/entities shall be notarized; and

3. The use of template for SS,attached hereto as ANNEX A, shall be voluntary for 2012Annual Financial Statements (AFS)but mandatory for 2013 AFSand onwards.

Mandaluyong City, Philippines, 18 April 2013.

For the Commission:

(/- f -- ...TERESITA J. HERBOSA

Chairman

,.

INSTRUCTIONS IN THE PREPARATIONOF SWORN STATEMENT OF SOURCES AND APPLICATION OF FUNDS

1 The Sworn Statement of Sources and Application of Funds is practically a statement accounting for thechange in FUND BAL\NCE from the beginning to the end of the current fiscal period. It does not account forthe change in CASH BALANCE. The said'statement should reconcile with the financial statement for evenperiod.

2 Please do not leave a"yspace blank. Disclosures may be made in the statement preferably in the form of asentence. N/A is disccuraged.

3 A 1 stands for Accomplished Project No. 1,A2 stands for Accomplished Project NO.2, so forth and so on. 01stands for On-Going Project NO.1, 02 for On~Going Project NO.2, so forth and so on.

4 S1 Stands for Source of Funds NO.1, and so on whereas AF stands for Schedule of Application ofFunds.

5 Sources and ApplicatiJn of Funds should be itemized by indicating the names and addresses of the Donorsand Payees identifyin[) their nationalities, the amount of contribution/donation and whether such amount isreceived in cash or as a non-cash contribution/donation. Non-cash receipts should disclose the Description ofthe noncash property, fair market value/best estimate and the date of receipt.Please refer closely to footnotes provided per proforma schedule.

6 Reporting Application of Funds should be on a project basis.

7 Please report/indicate the exact name or title of the project/activity of the foundation. All certifications ofproject existence shodd likewise indicate the exact title or name of the project/activity as reported in the

. Sworn Statement.

'.,

(Republic of the Philippines) SSCity ofC. )

SWORN STATEMENTWe "and-----.;----_ .•...----.•.....•

respectively of.. ' '.President and Treasurer,------- .•...-----...,;;... •• Foundation, Inc., with address at

.'.'. '...'hereby depose and state that:

In compliance with Section 4 of SEC Memorandum Circular NO.8 dated June 22, 2006 and SEC MemorandumCircular NO.4 dated March 7, 2013, we are stating the following information that relates to the preceding fiscal year

_______ ' to wit

. STATEMENTOF SOURCESAND APPLICATIONOF FUNDS(from:. .... 'to:.""';.)TOTAL MEMBER'S EQUITYI TOTAL FUND BALANCE .

PXXXI TOTAL CAPITAL I NET ASSETS BEGINNINGADD: Sources for the Period Ref. Amount(Breakdown of Total Receipts In the Sial .ment of Operational

S1 scned. of Contributions' Donations - Pnvate Entities S1'S2 Sched. of Contributions! uonatlons - uovemment Entitle S2S3 ' Schedule of Miscellanecus Income S3

!S4 Schedule of Otherlncorle S455 Others S5

Total Sources for the P$riod - PXXXLESS: Application of Fund.~Breakdown of Total Dlsbusements In the Statement of CA1 I Accomolished oroiect 1 -f>\1. A.ccomolished oroiect 2 -A3 Accomolished oroiect 3 AF -:01 On-aoina oroiect 1 -02 On-aoina oroiect 2 -

General Administrative and ('Deratina Exoenses -Total ADDlications for the Peri"d (PXXX)TOTAL MEMBER'S EQUITYI TOTAL FUND BALANCEI TOTAL CAPITAL I NET ASSETS ENDING PXXX

PLANNED PROGRAMS/ACTIVITIES(Year/s:;'/'}

Pro rams/Activities Officer-in Address/Contacts # Pro'ect Location

Note: Please see attached Inst, action Sheet

Further, we also state that:1 A certification from . •has been issued showing

that the projects within its jurisdiction exist. Copies of said certifications are herein attached.2 . '. '.'.•.;•.••.....',,;is willing to allow the Commission and/or

its duly authorized representative to conduct an audit and access its corporate and accounting booksof records during reasonable hours of business on any business day after due notice.

3 ..;.".... ",:';;,"s donated funds are all declaredand pf£sently deposited in bank accounts (from banks supervised by SSP) disclosed in Schedule CIS.

We hereby ce.tify that this. Sworn Statement with duly attached schedules is executed to attest to thetruth of the foregoing and for whatever legal purposes it may serve.

In witness tf1ereof, .we have hereunto affixed our signature this_,:,-'~_.<.,_-:-'<_.. ,:_,.-._,.,.,._",..,,_'<

..•...•.•.•.. .•.•.. __....•.•..._, Philippinesday of •.•••• 2013, at

President Treasurer

Subscribed and swo rn to before me, a Notary Public for and in City, on--~, affiants personally appeared, exhibiting their respective competent evidence of Identificationcard issued at issued on--------Doc. No.Page No.Book No.Series of 2013

NOTARY PUBLIC

Page 1 of 11

Name of FoundationSEC Registration No.:Period:

SCHEDULE OF CONTRIBUTIONS/DONATIONS. PRIVATE ENTITIES

Name of FoundatlonlOrgani2 ation:

For the year ended:

SEC Registration No.

I" S1 ISCHEDULE OF .;ONTRIBUTIONS/DONATIONS. PRIVATE ENTITIES

W ~ ~No. Narre and Address 1 National' 2

1

2

3

4

5

6

7

8

9

10

11

(e)T of Contribution 3

Cash 0Non/Cash 0

(Complete Part II if there isa noncash contribution)

Cash 0Non/Cash 0


Cash 0Non/Cash 0


Cash 0Non/Cash 0

(Complete Pari II if there isa noncash contribution)

Cash BNon/Cash

(Complete Part II if there is "8 noncash contribution)

Cash E3Non/Cash

(Comp/ete Part II if there isa noncash contribution)

Cash E3Non/Cash(Compl9te Perl II if there ;sa noncash contribution)

Cash E3Non/Cash(Comp/ete Pari II if there isa noncash contribution)

Cash E3NonlCash(Complete Part II if there isa noncash contribution)

" Cash 0NonlCash 0

(Comp/ete Part II if there isa noncash contribution)

Cash E3Non/Cash(Complete Perl II if there ;sa noncash contribution)

'A contributor or donor inclUdesindividuals, partnerships, corporations, associations, trusts and organizations.2'f supranational organization, indicate place of principal office or domicile.3Contributions or donations reportable on the Schedule are contributions, donations, grants, bequ.ests,devises,"and gifts ofmoney or property, amounting t) P100,000,00 or more from each contributor or donor.

Page 2 of 11

Name.of FoundationSEC Regislration No.:Period:

SCHEDULE OF CONTRIBUTIONS/DONATIONS. PRIVATE ENTITIES

I S1-A IName of Foundation/Orga!lization: SECRegistration No.

For the year ended:

I S1.A INoncash Property

(a)No.1

2

3

4

5

6

7

8

9

10

(d)Date received

Page 3 of 11

Name 01FoundationSEC Registration No.:Period:.

SCHEDULE OF CONTRIBUTIONSIDONATIONS • GOVERNMENT AND ITS INSTRUMENTALITIES

Name of Foundation/Organization:

For the year ended:


52 SCHEDULE OF CONTRIBUTIONS/DONATIONS.Government OfficerslOfficials or Government Offices, Agencies or Instrumentalities

(Note. Please USfl addItional fonnslshHIs or extend the fields for dISClosure if nfICessary}

TOTAL CONTRIBUTIONS/DONATIONS

(a) (bi (c) (d) (e)No. Government Uni: and Address 1 Authorizing OffIcer2 Total Contributions Type of Contribution1

Cash f:)Non/Cash(Complete Part /I if there ;sa nQncash contribution)

2Cash f:)Non/Cash

(Complete Part /I if there isa noncash contribution)

3Cash f:)Non/Cash

(Complete Part /I if there ;s. a noncash contribution)

4 Cash BNon/Cash

(Complele Part /I if there isa noncash contribution)

5Cash f:JNon/Cash .

(Complete Part /I if there ;sa noncash contribution)

6 Cash BNon/Cash


7 Cash BNQn/Cash


8 Cash BNon/Cash

(Complete Part /I if there ;sa noncash contribution)

9 Cash . f:)Non/Cash


10Cash f:)NonlCash


11 Cash BNon/Cash

(Complete Part /I if/here is.. a noncash contribution)

:ust ~own the name and add~Ss of the government office, agency or unit and specify its chapter, regional or extension office. if applicable.Identify the name of responsible officer/official or authority approving the donation/contribution to the foundation .

Page 4 of 11

"


SCHEDULE OF CONTRIBUTIONS/DONATIONS. GOVERNMENT AND ITS INSTRUMENTALITIESName of FoundationlOrganization: .

For the year ended:

I S2.A 'Noncash Propel'll

(a)No.1

2

3

4

5

6

7

8

9

10


(d)Date received

Page 5 of 11

"


53

SCHEDULE OF MISCELLANEOUS INCOMEName of Foundation/Organization: SEC Registration No.

For the year ended:

Amount

8

6 Refunds I ReimbursementsNature # 1 .Nature #2Nature # 3Nature # 4

7 Fair Value GalnsonTrad ingSecurlti ••Trading Securities #1 .Trading Securities # 2Trading Securities #3Trading Securities #4

4 Proceeds from sale of Property, Plant or Equipment ..PPE# 1 .

PPE#2PPE#3PPE#4

3 Dividend IncomeInvestee# 1Investee#2Investee#3Investee#4

2 RentallncomeLessee # 1Lessee #2Lessee # 3Lessee # 4

5 Gains on For:exTransactionsCash and Cash Equivalents .Receivables. .PayablesOthers

Schedule of Miscellaneous Income

No. Descri •on oflncome

Intereit Income from ba,~kdeposItsOndlcateFCDU*1f applicable) ....Bank # 1Bank#2Bank#3

(Note: Please use additional forms/sheets or extend the fields for disclosure If necessary)TOTAL MISCELLANEOUS INCOME

'Foreign Currency Deposit Unit

Page 6 of 11

,,r/'

/.///


SCHEDULE OF OTHER INCOME

84

Name of Foundation/Organization:

S4 ISchedule of Other Income I Other Sources of Funds

2

3

4

5

6

7

8

9

TOTAL OTHER INCOME


Page 70f1


55

OTHERSName of Foundation/Organization: SEC Registration No.

For the year/s ended:

S5 ISchedule of Other Sources of Funds other than listed in S1,S2,S3and S4.

(Note: Please use addItIonal forms/sheets or extend the fields for disclosure if necessary)TOTAL OTHER SOURCES

la) lb) Ie) ld)No. Nature Particulars Amount1 IBorrowings (Name of Lender and Address) Tenntol.faturity

.

2

3

4

5

6

7

8

..

Page 8 of 11

I_AF_IName of Foundation:

SEC Reg. No.:

Period:

STATEMENT OF APPLICATION OF FUNDS

.Particulars A1(PROJECT.T1Tl"E)

A2

(PROJE!CTTI'TLElr'

PROJECT INDEXA3 01

(PROJEl;T. TITLE)

02. ~.".: '..' "

(P,,"()JECT. '..'.. ttri..£):'

Gen. AdminOPEX

TOTAL

.' , -'.' .. '. .'.. : "" ':.' .'., "'::,:;'.,,:,: -

. '." ','.> ': .": , , ;,".'" ,'" -.. ,', .

:.: '.' :':i" .": .> -,

. ',' ':"'." .' .. ,",<, I".","" ,", -"

':" .... , ..... ' ,'" ...., .':'< ',. .,:> '\'i. '" -

:".'i,'.' ,.' " """':':"":.,>,",.',' "":':.',,,". -.

. . ::', ',:" .' ...... ,... ",.,', , ',.".,'.'\\ -... ", ,.'. ,' .... " " .::''':.'':, ",;,: -- - . . . . .

': ., '.' 'x,

... ."'. ':":":." '::.' ... ::.

,i:.:i' .. : "., ,'.".:: .:. "

:',', .: ". ,.,''', I',' '.

'I"".' . . ....

. '''', ., ..I'. ,.• c.. ,:., ,., I,... """,',o',i,:' I' ,::"",,: . ': ",' .,' ...

" .", "'."'>:::'1' '.,' ' .. i

:,; ,:"",.', ",."

": .

". "".,.':.,.:'" ,,' ,,', ;,'::'":'::,,, ".>':,: '..' '.'.: "',' .. ,c. .. " . '" ",,':,i" iF. "'. ,', "

. " . . ',." .":;' (, . , ' . '" '::':. ",:':",> "

, '," , I :'.',"': " .

". I"':""",'"

',I .

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, .

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.... " ,;,

'.. ',,,.' ., •....:','..:" ','.' .',

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--

Allocated Budget

CAPEX Iinventory:*Asset Class #1Asset Class #2Asset Class #3Asset Class #4Asset Class #5Inventory #1Inventory #2Inventory #3Inventory #4Subtotal

OPEX Breakdown:ConsultantsService ContractsTravels & TransportationTraining .Meetings & Conferences

SuppliesCommunicationsCourier and FreightUtilitiesBank ChargesPermits and LicensesDonationsRepairs & Maintenance

PromotionsDepreciationMiscellaneousSubtotalTOTAL Applications(Note: Please use additional form s/sheets or extend the fields for disclosure Hnecessary. Refer further to Instructions Sheet)

"Asset Class pertains to grouped items of asset per accounting policy identified in line with its nature, estimated useful life or use.(E,g. Office Equipment are identi,ied in an asset class separate from Land or Building)

Page 9 of 11

,0

Name:Reg. No.:

Period:-

ACCOMPLISHED/ON-GOING PROJECTS/PROGRAMS

PROJECTS BENEFICIARIES CERTIFICATE OFRefAccomplished (A) Officer-In- Addressl Project EXISTENCE

Charge Contact # LocationA1 A1A2 A2A3 . A3A4 . A4AS ASA6 A6A7 A7A8 A8A9 A9A10 A10A11 A11A12 A12A13 A13A14 A14

On-going (0) Officer-In- Address! ProjectChame Contact # Location

01 0102 0203 0304 0405 0506 0607 0708 0809 09010 010011 , 011012 012013 013(Note: Please use addlti onal forms/sheets or extend the fields for disclosure if necessary)

Page 10 of 11

'. •,.

Name:Reg. No.:

Period:

SCHEDULE OF BANK DEPOSITS

_C_IB_I

Account No. DeDositorv Bank (Branch) Bank Address Currency Amount in PHP

.

(Note: Please use additional forms/sheets or extend the fields for disclosure if necessary)

Page 11 of 11

Documents

SEC Building, EDSA, Greenhills, Mandaluyong Cit:1...TO RepublicofthePhilippines Department ofFinance Securities andExchange Commission SEC Building, EDSA, Greenhills, Mandaluyong Cit:1