Annex A

REPUBLIC OF THE PHILIPPINES)

_____________________________)S.S.

AFFIDAVIT

I, ________________________________, (nationality), of legal age,

with address at
_____________________________________________________ after
having been sworn in accordance with law hereby depose and state:

1. I am the (sole proprietor/president) is (business name/

corporate name), which is duly registered with the
((appropriate government agency) as being involved in the
((nature of business).

2. I hereby certify that (business name/ corporate name) is

“barangay – based” and “micro – business” in nature and scope
due to the following reasons:

a. (business name/ corporate name) is “barangay – based”

because (cite reasons why business is barangay - based
e.g. (i) the majority of employees are residents of the
municipality where the principal place of business is
located; or (ii) the principal business activity consists in the
application/use of a particular skill peculiar to the locality or
of raw materials predominantly sourced from the area; or
(iii) the business operations are confined within the
territorial jurisdiction of the municipality or local
government unit where principal place of business is
located); and
b. (business name/ corporate name) is “micro business” in
nature and scope because its principal business activity is
primarily for (livelihood or as a priority area for development
 or government assistance as determined by the SMED
Council of DTI); it is not a branch, subsidiary, division or office
of a large scale enterprise; and its policies and business modus
operandi are not determined by a large scale enterprise or by
persons who are not owners or employees of a large scale
enterprise.

3. I am executing this affidavit to attest to the truth of the foregoing

and for whatever legal purposes it may serve.

FURTHER AFFIANT SAYETH NAUGHT.

SUBSCRIBED AND SWORN to before me this ___ day of

_________________, 200__, affiant exhibiting to me his/her Community Tax
Certificate No. _______________________________ issued at
____________________ on ______________________.

__________________________
Notary Public

Doc No. ________;

Page No. _______;
Book no. _______;
Series of 200___.