Republic of the Philippines)City of ___________________)S.S.

SWORN STATEMENTI _______________________________, 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 Affidavit 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 __________________________.

_________________________Regional Director/

Schools Division Superintendent

FOR PALARONG PAMBANSA ONLY