Republic ofthe Philippines

Department of Finance
Securities and Exchange Commission
SEC Building, EDSA, Greenhills, Mandaluyong Cit:1

NOTICE

TO ALL FOUNDATIONS

SUBJECT GUIDELINES IN THE ACCOMPLISHMENT AND SUBMISSION OF

SWORN STATEMENT OF SOURCES, AMOUNT AND APPLICATION OF
FUND (SS) AND CERTIFICATE OF EXISTENCE OF PROGRAM/ACTIVITY
(COEP)

***************************************************************************

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

1. COEP shall be issued by the Office of the Mayor, thE~Office of the Barangay Chairman,
or the national or local office of either the Department of Social Welfare and
Development (DSWD) or the Department of Health (DOH), relative to the specific
program/activity of the foundation on the locality on which such government office
exercises jurisdiction;

2. COEP issued by Heads/Officers of private institution or actual beneficiaries/recipients of

the program/activity shall be allowed in lieu of COEP issued by the government
offices/entities specified in item 1 above: Provided, That COEPissued 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 2012
Annual 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 PREPARATION

OF SWORN STATEMENT OF SOURCES AND APPLICATION OF FUNDS

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

2 Please do not leave a"yspace blank. Disclosures may be made in the statement preferably in the form of a
sentence. 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. 01 stands
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 of Funds.

5 Sources and ApplicatiJn of Funds should be itemized by indicating the names and addresses of the Donors and
Payees identifyin[) their nationalities, the amount of contribution/donation and whether such amount is received in
cash or as a non-cash contribution/donation. Non-cash receipts should disclose the Description of the 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 of project
existence shodd likewise indicate the exact title or name of the project/activity as reported in the
. Sworn Statement.
 '.,

(Republic of the Philippines)

SS
City ofC. )

SWORN STATEMENT
We
-----.;----_ . ...----. .....
"and
-------
.
...-----......
.. ' '.President and Treasurer,
respectively of ,;; 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 Memorandum
Circular 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 PXXX

I TOTAL CAPITAL I NET ASSETS BEGINNING

ADD: Sources for the Period Ref. Amount
(Breakdown of Total Receipts In the Sial .ment of Operational
S1 scned. of Contributions' Donations - Pnvate Entities 'S2 S1
Sched. of Contributions! uonatlons - uovemment Entitle S3 ' S2
Schedule of Miscellanecus Income S3
!S4 Schedule of Otherlncorle S4
55 Others S5 - PXXX
Total Sources for the P$riod
LESS: Application of Fund.~
Breakdown of Total Dlsbusements In the Statement of C A1 I -
Accomolished oroiect 1
-

f>\1. A.ccomolishedoroiect
2 A3 Accomolished oroiect 3 -
:01 On-aoina oroiect 1 AF -
02 On-aoina oroiect 2 --

General Administrative and ('Deratina Exoenses

Total ADDlications for the Peri"d (PXXX)
TOTAL MEMBER'S EQUITYI TOTAL FUND BALANCE
I TOTAL CAPITAL I NET ASSETS ENDING PXXX

PLANNEDPROGRAMS/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 books of records
during reasonable hours of business on any business day after due notice.
3 ..;.".... ",:';;,"s donated funds are all declared
and pfsently 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 the truth of
the foregoing and for whatever legal purposes it may serve.
In witness tf1ereof, .we have hereunto affixed our signature this_,:,-'~_.<.,_-:-..'<,:_,.-._,..,,,'<.,._", day of .
2013, at
......... .... __......., Philippines

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 Identification

card issued at issued on -------- NOTARY PUBLIC

Doc. No.
Page No.
Book No.
Series of 2013
Page 1 of 11
Name of Foundation
SEC Registration No.:
Period:

SCHEDULE OF CONTRIBUTIONS/DONATIONS. PRIVATE ENTITIES

Name of FoundatlonlOrgani2 ation: SEC Registration No.

For the year ended:

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

W ~ ~ (e)
No. 1 National' T of Contribution 3
Narre and Address 2

1 Cash 0
Non/Cash 0
(Complete Part II if there is
a noncash contribution)

2 Cash
0
Non/Cash 0
(Complete Part II if there is

0
a noncash contribution)
3 Cash
Non/Cash 0
(Complete Part II if there is

4
a noncash contribution)
0
Cash
Non/Cash 0
(Complete Pari II if there a
noncash contribution)
5 Cash
is B
Non/Cash
(Complete Part II if there is "
8 noncash contribution)
E3
6 Cash
Non/Cash
(Comp/ete Part II if there is
a noncash contribution)

7 E3
Cash
Non/Cash
(Compl9te Perl II if there a ;s
noncash contribution)
E3
8 Cash
Non/Cash
(Comp/ete Pari II if there is
a noncash contribution)
E3
9 Cash
NonlCash
(Complete Part II if there is
a noncash contribution)
10 " Cash 0
NonlCash
(Comp/ete Part II if there
0
is
a noncash contribution)
E3
11 Cash
Non/Cash
(Complete Perl II if there a ;s
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 of money or property, amounting t) P100,000,00 or more from each contributor or donor.

Page 2 of 11
Name.of Foundation
SEC Regislration No.:
Period:
I S1-A I
SCHEDULE OF CONTRIBUTIONS/DONATIONS. PRIVATE ENTITIES

Name of Foundation/Orga!lization: SEC Registration No.

For the year ended:

I S1.A INoncash Property

(a) (d)
No. Date received
1

10

Page 3 of 11
Name 01Foundation
SEC Registration No.:
Period:.

SCHEDULE OF CONTRIBUTIONSIDONATIONS GOVERNMENT AND ITS INSTRUMENTALITIES

Name of Foundation/Organization: SEC Registration No.

For the year ended:

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

(a) (bi (c) (d) (e)

No. Government Uni: and Address
1
Authorizing OffIcer
2 Total Contributions Type of Contribution
1 Cash f:)
Non/Cash
(Complete Part /I if there ;s
a nQncash contribution)
2 Cash f:)
Non/Cash
(Complete Part /I if there is a
noncash contribution)
3 Cash f:)
Non/Cash
(Complete Part /I if there ;s
.
a noncash contribution)
4
Cash B
Non/Cash
(Complele Part /I if there is
a noncash contribution)
5
Cash f:J
Non/Cash .
(Complete Part /I if there ;s
a noncash contribution)
6
Cash
B
Non/Cash
(Complete Part /I if there is
a noncash contribution)
7
Cash B
NQn/Cash
(Complete Part /I if there is
a noncash contribution)
8
Cash
B
Non/Cash
(Complete Part /I if there ;s a
noncash contribution)
9 Cash . f:)

Non/Cash
(Complete Part /I if there is a
noncash contribution)
10
Cash f:)
NonlCash
(Complete Part /I if there is
a noncash contribution)
11
Cash
B
Non/Cash
(Complete Part /I if/here is

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

TOTAL CONTRIBUTIONS/DONATIONS

: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
"

Name of Foundation
SEC Registration No.:
Period:

SCHEDULE OF CONTRIBUTIONS/DONATIONS. GOVERNMENT AND ITS INSTRUMENTALITIES

Name of FoundationlOrganization: . SEC Registration No.

For the year ended:

I S2.A 'Noncash Propel'll

(a) (d)
No. Date received
1

10

Page 5 of 11
"

Name of Foundation
SEC Registration No.: 53
Period:

SCHEDULE OF MISCELLANEOUS INCOME

Name of Foundation/Organization: SEC Registration No.

For the year ended:

Schedule of Miscellaneous Income

No. Descri on oflncome

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

Lessee # 1
Lessee #2
Lessee # 3
Lessee # 4
3 Dividend Income

Investee# 1
Investee#2
Investee#3
Investee#4
4
Proceeds from sale of Property, Plant or Equipment . ..
PPE # 1
PPE#2
PPE#3
PPE#4
5 Gains on For:exTransactions

Cash and Cash Equivalents .

Receivables. .
Payables
Others
6 Refunds I Reimbursements

Nature # 1 .
Nature #2
Nature # 3
Nature # 4

7 Fair Value GalnsonTrad ingSecurlti

Trading Securities #1 .
Trading Securities # 2
Trading Securities #3
Trading Securities #4

(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
/
// ./

Name of Foundation
SEC Registration No.: 84
Period:

SCHEDULE OF OTHER INCOME

Name of Foundation/Organization: SEC Registration No.

S4 ISchedule of Other Income I Other Sources of Funds

TOTAL OTHER INCOME

Page 70f1
Name of Foundation
SEC Registration No.: 55
Period:

OTHERS
Name 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.

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

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

Page 8 of 11
Name of Foundation:
SEC Reg. No.:
I_AF_I
Period:

STATEMENT OF APPLICATION OF FUNDS

PROJECT INDEX
.Particulars A1 A2 A3 01 02 Gen. Admin TOTAL
(PROJECT (PROJE!CT (PROJEl;T . ~".: . " ' .'
'. OPEX
(P,,"()JECT.
.T1Tl"E) TI'TLElr' . TITLE) .'.. ttri..):'
Allocated Budget
CAPEX Iinventory:*
.'
, -
Asset Class #1 '.'
Asset Class #2 .. '.
.'.. :
""

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

--
Asset Class #3 . '." .": , , ;,".'" ,'"
','.>':
Asset Class #4 . ',' ':"'." .. ,',. :.: '.' :':i" I".","" .": .>
Asset Class #5 , .' .. ,",<, ,",
-
-
"
.... ,.....
Inventory #1 ':" ' ,'" .... , .':' < ',. .,:> '\'i. '"
Inventory #2 . :".'i,'.' , .'
"

"""':':"":.,>,",.',' "":':.',,,". -
Inventory #3
. . ::', ',:" .'
...... ,...
",.,', , ',.".,'.'\\ -
Inventory #4 ... ", ,.'. ,' .... " .::''':.'':, ",;,:
-
.
"

-
Subtotal
- . . . .
OPEX Breakdown: ',,, ". "".,.':.,.:'" ,,' ,,', ;,'::'":'::,,, ".>':,: '..' '.
'..
Consultants
Service Contracts :','. '.: "',' ,c. .. " .
..
iF. "'. ,', "
",,':,i"
.' ., ....
',." '"

'" '::':
" .

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

Travels & Transportation .:" . (, .
.

Training . .... \.:. . ",:':",> "

Meetings & Conferences , '," , I :'.',"': " .
.. ,:..:.:'" ".

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

.'
.

',I .
Communications .. ":
': .
.... ,;, , '.' 'x,
Courier and Freight "

'::.'
... ':":":." ...::.
Utilities ."'.
Bank Charges ,i:.:i' .. : "., ,'.".:: .:. "
"

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

Permits and Licenses :',', 'I"".' .: ". ,.,''', I',' '.

Donations .
. . ....
,:.,

Repairs & Maintenance . '''', ., ..I'. ,. c.. ,., I,... """ .,' ...

Promotions '. ,',o',i,:' I' ,::"",,: . ': ",'

, . i
Depreciation " .", "'."'>:::'1' '.,' ' ..
Miscellaneous :,; ,:"",.',
.'
.. ",."

Subtotal -
TOTAL Applications
-
(Note: Please use additional form s/sheets or extend the fields for disclosure
H necessary. 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
Ref CERTIFICATE OF
Accomplished (A) Officer-In- Addressl Project
EXISTENCE
Charge Contact # Location
A1 A1
A2 A2
.
A3 A3
.
A4 A4
AS AS
A6 A6
A7 A7
A8 A8
A9 A9
A10 A10
A11 A11
A12 A12
A13 A13
A14 A14
On-going (0) Officer-In- Address! Project
Chame Contact # Location
01 01
02 02
03 03
04 04
05 05
06 06
07 07
08 08
09 09
010 010
, 011
011
012 012
013 013
(Note: Please use addlti onal forms/sheets or extend the fields for disclosure if necessary)

Page 10 of 11
 '. ,.

Name:
Reg. No.:
Period:
_C_IB_I
SCHEDULE OF BANK DEPOSITS
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