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Sworn Certification for Stock Corporation or Investee Firm

TIEZA sworn certification for stock corporation or investee firm

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: APPENDIX 10.3A
Page 1 of 3
(As amended by Circular No. 742 dated 21 November 2011 and Circular No. 794 dated 18 April 2013)

SWORN CERTIFICATION
(Suggested Format for Stock Corporation/Investee Firm)

I, _____________________________, of legal age, ___________________, and
(Name of Affiant)

(Nationality)

resident of the Philippines, after being duly sworn in accordance with law, depose
and state that:
1. I am the _____________________ of ______________________________________,
(Position/Designation)

(Name of Investee-Firm)

a corporation duly registered with/licensed by the Philippine Securities and Exchange
Commission (SEC) under SEC Reg. No. ________ dated _________, to engage in the
business of ___________________________________________________________
___________________________________________________________________.
2. That the _________________________________ has a Capital Structure, as follows:
(Name of Investee Firm)

Class

Number of Shares

Par Value

Total Amount

Authorized

_____

______________

________

___________

Subscribed

_____

______________

________

___________

Paid Up

_____

______________

________

___________

3. That _____________________________, ______________________, with address
(Name of Foreign Investor)

(Nationality)

at __________________________________________________________________,
whose business is ______________________________________________________,
has remitted/caused the remittance of USD/Other Foreign Currency (FC)
________________________________________, and converted the same into
PHP _________ (if applicable), thru the Philippine banking system as certified by
____________________ under Certificate of Inward Remittance (CIR) of Foreign
(Name of Issuing Bank)

Exchange No.___________ dated ____________________, of which amount,
PHP/foreign currency ____________________ was paid in consideration for the
following shares of the Investee-Firm1 and is now recorded in his/its name in the
books of ______________________, as follows:
(Name of Investee-Firm)

1

The balance (total peso/USD/other foreign currency proceeds less amount applied to this investment
transaction, if any) in the amount of PHP_______________ is recorded in the books of
(Name of Investee-Firm) as (e.g. Advances, Deposit for Future Subscription).

APPENDIX 10.3A
Page 2 of 3
(As amended by Circular No. 742 dated 21 November 2011 and Circular No. 794 dated 18 April 2013)

Amount booked as payment for shares
(in PHP, USD or other foreign currency)
Class

No. of Shares
Paid For

Par
Value/Share

Total Par Value

As Premium

Total

4. That of the above total, the following share/s was/were assigned to cited Foreign
Investor’s nominee/s (if any):
Name
Nationality
No. of Shares
Amount Paid
________________ _____________ _________________ _______________
________________ _____________ _________________ _______________
(The following paragraph may follow as appropriate)
That the aforecited nominee/s appear/s in the corporate books of the
_________________________________________________ only as nominee/s of the
(Name of Investee-Firm)

_____________________________________ and that the said share/s is/are covered
(Name of Foreign Investor)

by Deed/s of Assignment of Foreign Investor transferring the share/s to each of the
nominee named above; and that the covering certificates of stock issued to the said
nominee/s are with annotation/s that the said nominee/s is/are merely nominee/s of
the foreign investor named above;
5. That in the corporate books of _______________________________________ as of
(Name of Investee-Firm)

__________________ show that the following are the stockholdings of its investors:
(current date)

Name of Investor
No. of Shares Held
__________________ _____________
__________________ _____________
__________________ _____________

Class
_______________
_______________
_______________

Amount Paid
_______________
_______________
_______________

Correspondingly, the capital stock of the _______________________________as of
(Name of Investee Firm)

____________________________ is as follows:
(Current Date)
Number of Shares
Common
Issued and Paid
Filipino
Foreign
Additional Paid-In Capital
Deposit for future subscription

Preferred

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Amount
(in PHP)

%

APPENDIX 10.3A
Page 3 of 3
(As amended by Circular No. 742 dated 21 November 2011 and Circular No. 794 dated 18 April 2013)

6. That as of date, total foreign investments in the percentage stated above in the
________________________________ is within the limit for foreign investor
under
(Name of Investee-Firm)

the Constitution and existing laws of the Philippines.

I have hereunto set my hand this
___________________ 20__ at ____________________.

___________

day

of

___________________________
(Signature over Printed Name)

SUBSCRIBED AND SWORN TO before me this _____ day of _____________
20___, at __________, Philippines affiant exhibiting his/her (government-issued
identification card) no. ______________issued on ________________ at
_________________, Philippines.

Witness my hand and notarial seal on the date and place above-written.
NOTARY PUBLIC
Doc. No. __;
Page No. __;
Book No. __;
Series of ___.
N.B. The above form may be amended as appropriate.
 
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