Republic of the Philippines)

City of ___________________)S.S.

SWORN STATEMENT
I DINA S. BELLEZAS, of legal age, single, with postal address at
Divisoria, Cawayan, Masbate, after having duly sworn in accordance
with law hereby depose and state:

That I am presently employed with the Private Institution as

Teacher;

That I have been employed in Western Masbate Roosevelt High

School since June 1, 2014 or for a period of 4 years;

That I was designated as Chaperon of Table Tennis (Secondary-

Girls), who will participate in the 2018 Palarong Bikol;

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

That all the athletes of Table Tennis (Secondary-Girls), who will

participate in the 2018 Palarong Bikol 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 22 nd

day of January, 2018 in Masbate City, Masbate, Philippines.

DINA S. BELLEZAS
Affiant

SUBSCRIBED AND SWORN TO before me this 2nd day of

January, 2018 in Masbate City affiant exhibiting to me her
Community Tax Certificate No. 10230964 issued on January 8, 2018
in Poblacion, Cawayan, Masbate.

_________________________
SDS / Administrative Officer

Doc. ______;
Page No. ______;
Book No. ______;
Series of 2018.