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REPUBLIC OF THE PHILIPPINES )

Municipality of Palo ) S.S.


Province of Leyte )

AFFIDAVIT

I, _______________________________, Filipino, of legal age, single/married and


a resident of __________________________________, Philippines, after having been
duly sworn to in accordance with law, hereby depose and say: - THAT -

1. I am presently employed with the Bureau of Internal Revenue –


Revenue Region No. 14 (Eastern Visayas), assigned at the
__________________________________________________;

2. I am a beneficiary of the Presidential Social Fund (PSF) Financial


Assistance accorded to government employees of the National
Government Agencies (NGAs) in Region VIII, who were affected by
Super Typhoon Yolanda last November 8, 2013;

3. As beneficiary, I am qualified to claim the amount of One Hundred


Thousand Pesos (Php 100,000.00) given to those whose properties
were TOTALLY DAMAGED;

4. Last December 2015, I received the initial amount of Fifty Thousand


Pesos (Php 50,000.00) covering the First (1st) Tranche of the aforesaid
PSF Financial Assistance;

5. I have fully and meticulously complied with all the liquidation and
documentary requirements needed for the release of the remaining
amount (2nd Tranche) of Fifty Thousand Pesos (Php 50,000.00) and
that the same had been forwarded and submitted to the BIR
National Office for processing; and

6. I am executing this Affidavit freely and voluntarily in order to establish


the truth of the foregoing facts and as a requirement for the release
of the 2nd Tranche PSF Financial Assistance and for all legal intents
and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ of May 2019 at
the BIR Regional Office, Government Center, Palo, Leyte, Philippines.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of May 2019 in the BIR
Regional Office, Government Center, Palo, Leyte, Philippines, affiant having
exhibited to me his/her BIR Identification No. _________________.

Doc. No. _______;


Page No. _______;
Book No.________;
Series of 2019.
REPUBLIC OF THE PHILIPPINES )
Municipality of Palo ) S.S.
Province of Leyte )

AFFIDAVIT

I, _______________________________, Filipino, of legal age, single/married and


a resident of __________________________________, Philippines, after having been
duly sworn to in accordance with law, hereby depose and say: - THAT -

1. I am presently employed with the Bureau of Internal Revenue –


Revenue Region No. 14 (Eastern Visayas), assigned at the
__________________________________________________;

2. I am a beneficiary of the Presidential Social Fund (PSF) Financial


Assistance accorded to government employees of National
Government Agencies (NGAs) in Region VIII, who were affected by
Super Typhoon Yolanda last November 8, 2013;

3. As beneficiary, I am qualified to claim the amount of Thirty Thousand


Pesos (Php 30,000.00) given to those whose properties were
PARTIALLY DAMAGED;

4. Last December 2015, I received the initial amount of Fifteen


Thousand Pesos (Php 15,000.00) covering the First (1st) Tranche of the
aforesaid PSF Financial Assistance;

5. I have fully and meticulously complied with all the liquidation and
documentary requirements needed for the release of the remaining
amount (2nd Tranche) of Fifteen Thousand Pesos (Php 15,000.00) and
that the same had been forwarded and submitted to the BIR
National Office for processing; and

6. I am executing this Affidavit freely and voluntarily in order to establish


the truth of the foregoing facts and as a requirement for the release
of the 2nd Tranche PSF Financial Assistance and for all legal intents
and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ of May 2019 at
the BIR Regional Office, Government Center, Palo, Leyte, Philippines.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of May 2019 in the BIR
Regional Office, Government Center, Palo, Leyte, Philippines, affiant having
exhibited to me his/her BIR Identification No. _________________.

Doc. No. _______;


Page No. _______;
Book No.________;
Series of 2019.