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12-2 Sworn Statement of Apprehending Officer

MGB sworn statement for apprehending officer for mineral processing

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SWORN STATEMENT OF APPREHENDING OFFICER
REPUBLIC OF THE PHILIPPINES
Municipality of ______________
Province of __________________

AFFIDAVIT
I, ____________________________________, of legal age and a resident of
___________________________________________________, after being duly sworn,
depose and state:
1. That I am a/an ____________________________ of the Department of Environment
(Position)
and Natural Resources, Region __________________ with place of assignment at
____________________________________________________________________;
2. That on or about _______________________ at ________________________, I was
_____________________________________________________________________
____________________________________________________________________;
(state activity such as conducting surveillance, patrolling, etc.)
3. That in the course of performance of my work on or about ________ in
______________________________________________ I apprehended a certain
____________________________________________________________________
for having mined, extracted, quarried, excavated, removed, transported and /or
possession of mineral commodities termed/called/described as __________________
______________________________________ with a total volume/tonnage/quality
________________________________________ cu. m/tons/kilos/grams/bags/sacks
and with an estimated value of
P___________________ without a permit or
license or legal supporting documents;
4. That said mineral commodities/products were mined, extracted, quarried, excavated,
transported and/or possessed without permit, license or legal supporting documents
upon order of ________________________________ company more particularly,
____________________________
who are officials of said company or
corporation.
IN WITNESS WHEREOF, I have hereto signed the affidavit this ____________
day of ____________________ , 19 _____ at ______________________________ .

_______________________
Affiant
TIN _________________

MGB Form No. 12-2

ACKNOWLEDGEMENT
Republic of the Philippines _____ )
Province of ________________ ) S. S.
City/Municipality of _________ )
SUBSCRIBED AND SWORN to before me at the place aforesaid, on this
__________ day of ____________________, 19_____. The affiant exhibited to me
his/her Community Tax Certificate No. ____________ issued at ___________ on the
___________ day of _______________, 19____.
___________________________
NOTARY PUBLIC
Until Dec. 31, 19 ______
PTR No. ____________
Doc. No.
Page No.
Book No.
Series of

_______
_______
_______
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