FORM
Commission on Elections ARC
October 30, 2023
Synchronized Barangay and Sangguniang Kabataan Elections
Authority to Receive Contribution
Date filed:
The undersigned candidate hereby grants the authority to his/her agent,
,
(SURNAME) (FIRST NAME) (MIDDLE NAME) (EXT. )
To receive contributions and issue receipts for the same on behalf of the candidate, 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:
CANDIDATE INFORMATION: Accomplish this part only if you are a candidate)
NAME OF
CANDIDATE: (SURNAME) (FIRST NAME) (MIDDLE NAME) (EXT)
Constituency of the Elective
Elective Position (Barangay,
Position City/Municipality, Province,
Region)
Contact information:
(Phone no. & e-mail address)
AGENT INFORMATION: (Person authorized to receive contributions, whose name appears in main body)
Home/
Office
Address:
Telephone
& Mobile E-mail Address:
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:
Name Doc. Type ID No. Expiry 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.:
Page No.:
Book No.:
NOTARY PUBLIC
Series of
