Project Reference Number ______________________________________________________

Name of the Project ______________________________________________________

Standard Form Number: SF-GOOD-12

Revised on: May 24, 2004

AFFIDAVIT OF DISCLOSURE OF NO RELATIONSHIP

I, ______________________, of legal age, __(civil status)__, residing at _____________________________ after being sworn in accordance with law, do hereby depose and say:

1. That I am the authorized representative of __(Name of Bidder)__ with office address at ___(Address of Bidder)____;

2. That the firm/partnership/joint venture/corporation, or any of its officers, directors , controlling stockholders and members, I represent for the bidding of ____(Name of Project)_____, is not related by consanguinity or affinity up to the third civil degree to the head of agency, to the BAC, TWG or Secretariat members, or to any Procuring Entity official, who directly or indirectly took part in the bidding process;

3. That I am making this statement in compliance with Section 47 of the Implementing Rules and Regulations of Republic Act No. 9184, and in accordance with the requirements of the Local Government Unit of General Santos City - BAC.

IN WITNESS WHEREOF, I have hereunto set my hand this _________________ day of __________________, 20__, in the City of __________________, Philippines.

___________________

Affiant

SUBSCRIBED AND SWORN to before me this ___________________________ day of _____________________, Philippines.

___________________

Notary Public

Doc. No. __________;

Page No. __________;

Book No. __________;

Series of 20 __