Commission on Elections

FORM
May 13, 2019
National and Local Elections ARC
Authority to Receive Contribution
Date filed:

The undersigned candidate/party treasurer hereby grants the authority to his/her agent,
, ,
(SURNAME) (FIRST NAME) (MIDDLE NAME)

to receive contributions and issue receipts for the same on behalf of the candidate or party, with the
understanding and undertaking that the undersigned shall be responsible for the actions of the said agent.

AFFIX SIGNATURE HERE 

Before printing, encode name here  [NAME OF CANDIDATE]
Date signed:

ELECTORAL PARTY INFORMATION: Accomplish this part only if you are the party treasurer
NAME of
PARTY (SURNAME) (FIRST NAME) (MIDDLE NAME)
TREASURER:
NAME OF
PARTY: (COMPLETE NAME OF PARTY) (ACRONYM)
 Political Party Contact information:
PARTY TYPE:  Party-List Group (Phone no. & e-mail address)

CANDIDATE INFORMATION: Accomplish this part only if you are a candidate)

NAME OF
CANDIDATE: (SURNAME) (FIRST NAME) (MIDDLE NAME)
Elective office District, Municipality/city/province
sought: of elective office:
Contact information:
Name of party:
(Phone no. & e-mail address)

AGENT INFORMATION: (Person authorized to receive contributions, whose name appears in main body)
Home/Office
Address:
Telephone &
E-mail Address:
Mobile No.:

ACKNOWLEDGMENT
REPUBLIC OF THE PHILIPPINES )
City/Municipality of __________________)

BEFORE ME, on (date) and in (city/municipality) , personally appeared the following persons with
competent evidence of their identity:
Expiry
Name Doc. Type ID No. Date Issuing Authority

Said persons acknowledged under oath to me under penalty of law, that the whole contents of this document
are true and the same are their free and voluntary acts and deeds.

WITNESS MY HAND AND NOTARIAL SEAL.

Doc. No.: NOTARY PUBLIC

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