ANNEX D

Omnibus Sworn Statement (Revised)[shall be submitted with the Bid]_________________________________________________________________________REPUBLIC OF THE PHILIPPINES )CITY/MUNICIPALITY OF ______ ) S.S.

AFFIDAVIT
I, [Name of Affiant], of legal age, [Civil Status], [Nationality], and residing at [Address ofAffiant], after having been duly sworn in accordance with law, do hereby depose and statethat:
1. [Select one, delete the other:][If a sole proprietorship:] I am the sole proprietor or authorized representative of [Name ofBidder] with office address at [address of Bidder];[If a partnership, corporation, cooperative, or joint venture:] I am the duly authorized anddesignated representative of [Name of Bidder] with office address at [address of Bidder];2. [Select one, delete the other:][If a sole proprietorship:] As the owner and sole proprietor, or authorized representative of[Name of Bidder], I have full power and authority to do, execute and perform any and allacts necessary to participate, submit the bid, and to sign and execute the ensuing contract
for [Name of the Project] of the [Name of the Procuring Entity], as shown in the attachedduly notarized Special Power of Attorney;[If a partnership, corporation, cooperative, or joint venture:] I am granted full power andauthority to do, execute and perform any and all acts necessary to participate, submit thebid, and to sign and execute the ensuing contract for [Name of the Project] of the [Nameof the Procuring Entity], as shown in the attached [state title of attached document showingproof of authorization (e.g., duly notarized Secretary’s Certificate, Board/Partnership
Resolution, or Special Power of Attorney, whichever is applicable;)];3. [Name of Bidder] is not “blacklisted” or barred from bidding by the Government of thePhilippines or any of its agencies, offices, corporations, or Local Government Units, foreign
government/foreign or international financing institution whose blacklisting rules havebeen recognized by the Government Procurement Policy Board, by itself or by relation,membership, association, affiliation, or controlling interest with another blacklisted
person or entity as defined and provided for in the Uniform Guidelines onBlacklisting;
4. Each of the documents submitted in satisfaction of the bidding requirements is anauthentic copy of the original, complete, and all statements and information provided
therein are true and correct;
5. [Name of Bidder] is authorizing the Head of the Procuring Entity or its duly authorized
representative(s) to verify all the documents submitted;
6. [Select one, delete the rest:]

[If a sole proprietorship:] The owner or sole proprietor is not related to the Head of theProcuring Entity, members of the Bids and Awards Committee (BAC), the TechnicalWorking Group, and the BAC Secretariat, the head of the Project Management Office or
the end-user unit, and the project consultants by consanguinity or affinity up to the third
civil degree;[If a partnership or cooperative:] None of the officers and members of [Name of Bidder] isrelated to the Head of the Procuring Entity, members of the Bids and Awards Committee(BAC), the Technical Working Group, and the BAC Secretariat, the head of the ProjectManagement Office or the end-user unit, and the project consultants by consanguinity oraffinity up to the third civil degree;[If a corporation or joint venture:] None of the officers, directors, and controllingstockholders of [Name of Bidder] is related to the Head of the Procuring Entity, membersof the Bids and Awards Committee (BAC), the Technical Working Group, and the BAC
Secretariat, the head of the Project Management Office or the end-user unit, and theproject consultants by consanguinity or affinity up to the third civil degree;
7. [Name of Bidder] complies with existing labor laws and standards; and8. [Name of Bidder] is aware of and has undertaken the responsibilities as a Bidder incompliance with the Philippine Bidding Documents, which includes:
a.
b.
c.
d.

Carefully examining all of the Bidding Documents;
Acknowledging all conditions, local or otherwise, affecting the implementation of theContract;
Making an estimate of the facilities available and needed for the contract to be bid, ifany; andInquiring or securing Supplemental/Bid Bulletin(s) issued for the [Name of theProject].

9. [Name of Bidder] did not give or pay directly or indirectly, any commission, amount, fee, or
any form of consideration, pecuniary or otherwise, to any person or official, personnel orrepresentative of the government in relation to any procurement project or activity.
10. In case advance payment was made or given, failure to perform or deliver any of theobligations and undertakings in the contract shall be sufficient grounds toconstitute criminal liability for Swindling (Estafa) or the commission of fraud with
unfaithfulness or abuse of confidence through misappropriating or converting any
payment received by a person or entity under an obligation involving the duty todeliver certain goods or services, to the prejudice of the public and the governmentof the Philippines pursuant to Article 315 of Act No. 3815 s. 1930, as amended, orthe Revised Penal Code.
IN WITNESS WHEREOF, I have hereunto set my hand this __ day of ___, 20__ at____________, Philippines.
[Insert NAME OF BIDDER OR ITS AUTHORIZEDREPRESENTATIVE][Insert signatory’s legal capacity]
Affiant[Jurat][Format shall be based on the latest Rules on Notarial Practice]