ANNEX D

Omnibus Sworn Statement
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 state that:
1. Select one, delete the other:
If a sole proprietorship: I am the sole proprietor of [Name of Consultant] with officeaddress at [address of Consultant];
If a partnership, corporation, cooperative, or joint venture: I am the duly authorized anddesignated representative of [Name of Consultant] with office address at [address ofConsultant];
2. Select one, delete the other:
If a sole proprietorship: As the owner and sole proprietor of [Name of Consultant], I
have full power and authority to do, execute and perform any and all acts necessary torepresent it in the bidding for [Name of the Project] of the [Name of the Procuring
Entity];If a partnership, corporation, cooperative, or joint venture: I am granted full power andauthority to do, execute and perform any and all acts necessary and/or to represent the[Name of Bidder] in the bidding as shown in the attached [state title of attacheddocument showing proof of authorization (e.g., duly notarized Secretary’s Certificate
issued by the corporation or the members of the joint venture)];3. [Name of Consultant] is not “blacklisted” or barred from bidding by the Government ofthe Philippines or any of its agencies, offices, corporations, or Local Government Units,
foreign government/foreign or international financing institution whose blacklisting rules
have been recognized by the Government Procurement Policy Board;
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 Consultant] 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: I am not related to the Head of the Procuring Entity, members ofthe 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;
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 Consultant] is related to the Head of the Procuring Entity,
members of the Bids and Awards Committee (BAC), the Technical Working Group, andthe BAC Secretariat, the head of the Project Management Office or the end-user unit, andthe project consultants by consanguinity or affinity up to the third civil degree;
7. [Name of Consultant] complies with existing labor laws and standards; and8. [Name of Consultant] is aware of and has undertaken the following responsibilities as aBidder:a) Carefully examine all of the Negotiation Documents;b) Acknowledge all conditions, local or otherwise, affecting the implementation of theContract;c) Made an estimate of the facilities available and needed for the contract to be bid, ifany; andd) Inquire or secure Supplemental/Bid Bulletin(s) issued for the [Name of the Project].

IN WITNESS WHEREOF, I have hereunto set my hand this __ day of ___, 20__ at____________, Philippines.

[Insert NAME OF CONSULTANT’SAUTHORIZED REPRESENTATIVE][Insert signatory’s legal capacity]
Affiant

SUBSCRIBED AND SWORN to before me this __ day of [month] [year] at [place ofexecution], _______________. Affiant/s is/are personally known to me and was/were identified
by me through competent evidence of identity. Affiant/s exhibited to me his/her [insert type ofgovernment identification card used], with his/her photograph and signature appearing thereon,
with no. ______ and his/her Community Tax Certificate No. _______ issued on ______ at______.
Witness my hand and seal this ___ day of [month] [year].

NAME OF NOTARY PUBLIC
Serial No. of Commission ___________
Notary Public for ______ until _______
Roll of Attorneys No. _____PTR No. __, [date issued], [place issued]
IBP No. __, [date issued], [place issued]

Doc. No. ___Page No. ___Book No. ___Series of ____.