Republic of the Philippines)

City of ___________________)S.S.

SWORN STATEMENT
I _______________________________, of legal age, single/married,
with postal address at___________________________ ,after having duly
sworn in accordance with law hereby depose and state:

That I am presently employed with the __________________ as

_______________________;

That I have been employed in ______________________________

since _____________________or for a period of _______________;

That I was designated as coach of _______________________, who

will participate in the 20__ Palarong Pambansa;

That all the athletes records submitted are true and correct to
the best of my personal knowledge;

That all the athletes of _________________, who will participate

in the 20__ Palarong Pambansa are eligible;

That I execute this Sworn Statement to attest to the

authenticity and veracity of all the documents submitted.

IN WITNESS WHEREOF, I have hereunto set my hand this

_______ day of _____________________20__ in ________________________,
Philippines.

__________________
Affiant

SUBSCRIBED AND SWORN TO before me this ________day of

_________________, 20__ in _____________________, affiant exhibiting to
me his/her Community Tax Certificate No. ______________________,
issued on ______________________ in __________________________.

_________________________
SDS / Administrative Officer