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Annex A

REPUBLIC OF THE PHILIPPINES) _____________________________)S.S.

AFFIDAVIT

I, ________________________________, (nationality), of legal age, with address at after

_____________________________________________________ having been sworn in accordance with law hereby depose and state:

1.

I am the (sole proprietor/president) is (business name/ corporate name), which is duly registered with the

((appropriate government agency) as being involved in the ((nature of business).

2.

I hereby certify that (business name/ corporate name) is “barangay – based” and “micro – business” in nature and scope due to the following reasons:

a.

(business name/ corporate name) is “barangay – based” because (cite reasons why business is barangay - based e.g. (i) the majority of employees are residents of the municipality where the principal place of business is located; or (ii) the principal business activity consists in the application/use of a particular skill peculiar to the locality or of raw materials predominantly sourced from the area; or (iii) the business operations are confined within the territorial jurisdiction of the municipality or local

government unit where principal place of business is located); and b. (business name/ corporate name) is “micro business” in nature and scope because its principal business activity is primarily for (livelihood or as a priority area for development

or government assistance as determined by the SMED Council of DTI); it is not a branch, subsidiary, division or office of a large scale enterprise; and its policies and business modus operandi are not determined by a large scale enterprise or by persons who are not owners or employees of a large scale enterprise.

3.

I am executing this affidavit to attest to the truth of the foregoing

and for whatever legal purposes it may serve.

FURTHER AFFIANT SAYETH NAUGHT.

SUBSCRIBED AND SWORN to before me this ___ day of _________________, 200__,...