Republic of the Philippines

Commission on Elections

14 MAY 2018 Synchronized Barangay and Sangguniang Kabataan Elections

STATEMENT OF CONTRIBUTIONS AND EXPENDITURES

NAME: ________________________________________________________ POSITION: ______________________

CELLPHONE NUMBER:

ADDRESS: ___________________________________________________ __________________________________

E-MAIL ADDRESS:
_______________________________________________________________
__________________________________

A.CONTRIBUTIONS RECEIVED:

1. Total amount of contributions received: Php

B. EXPENDITURES INCURRED:

1. From personal cash: Php

2. From contributions received: Php
____________________________________

TOTAL EXPENDITURES INCURRED: Php

ACKNOWLEDGMENT

I, _________________________________, after being duly sworn to, hereby depose and state that:

(1) This Statement and its attached Annexes are supported by receipts, vouchers, and other
documentsreflecting the full, true, accurate and complete election contributions received and
expenditures incurred by me and /or by my duly authorized representative;
(2) The expenditures incurred by me are for lawful purposes and the contributions were not received from
persons or entities prohibited by law to give contributions.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _______ day of _______ 2018.

__________________________________
(Name and Signature of Candidate)

SUBSCRIBED AND SWORN to before me this _______ day of ________________2018, candidate

exhibiting his/her __________________________with number ________________ issued by
____________________________________ with expiry date __________________________.

ADMINISTERING OFFICER