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FN Sworn Statement
SEC statement of FN sworn
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: (Republic of the Philippines) SS
City of (
)
SWORN STATEMENT
We
respectively of
and
President and Treasurer,
Foundation, Inc., with address at
hereby depose and state that:
In compliance with Section 4 of SEC Memorandum Circular No. 8 dated June 22, 2006 and SEC Memorandum
Circular No. 4 dated March 7, 2013, we are stating the following information that relates to the preceding fiscal year
, to wit:
STATEMENT OF SOURCES AND APPLICATION OF FUNDS (from:
TOTAL MEMBER'S EQUITY/ TOTAL FUND BALANCE
/ TOTAL CAPITAL / NET ASSETS, BEGINNING
ADD: Sources for the Period
to:
P XXX
Ref.
(Breakdown of Total Receipts in the Statement of Operations)
Amount
(S1) Sched. of Contributions / Donations - Private Entities
S1
(S2) Sched. of Contributions / Donations - Government Entities
S2
(S3) Schedule of Miscellaneous Income
S3
(S4) Schedule of Other Income
S4
(S5) Others
S5
Total Sources for the Period
LESS: Application of Funds
(Breakdown of Total Disbursements in the Statement of Operations)
(A1) Accomplished project 1
(A2) Accomplished project 2
(A3) Accomplished project 3
AF
(O1) On-going project 1
(O2) On-going project 2
General Administrative and Operating Expenses
-
(PXXX)
P XXX
PLANNED PROGRAMS/ACTIVITIES (Year/s:
Programs/Activities
P XXX
-
Total Applications for the Period
TOTAL MEMBER'S EQUITY/ TOTAL FUND BALANCE
/ TOTAL CAPITAL / NET ASSETS, ENDING
P1
P2
)
Officer-in
Address/Contacts #
)
Project Location
Note: Please see attached Instruction Sheet
Further, we also state that:
1 A certification from
has been issued showing
that the projects within its jurisdiction exist. Copies of said certifications are herein attached.
2
is willing to allow the Commission and/or
its duly authorized representative to conduct an audit and access its corporate and accounting books
of records during reasonable hours of business on any business day after due notice.
3
's donated funds are all declared
and presently deposited in bank accounts (from banks supervised by BSP) disclosed in Schedule CIB.
We hereby certify that this Sworn Statement with duly attached schedules is executed to attest to the
truth of the foregoing and for whatever legal purposes it may serve.
In witness thereof, we have hereunto affixed our signature this
, Philippines
President
day of
Treasurer
Subscribed and sworn to before me, a Notary Public for and in _______________________ City, on
______, affiants personally appeared, exhibiting their respective competent evidence of Identification
card_______________ issued at _________________ issued on _________________.
Doc. No.
Page No.
Book No.
Series of
NOTARY PUBLIC
2013
Page 1 of 11
Name of Foundation
SEC Registration No.:
Period:
S1
SCHEDULE OF CONTRIBUTIONS/DONATIONS - PRIVATE ENTITIES
Name of Foundation/Organization:
SEC Registration No.
For the year ended:
S1
(a)
SCHEDULE OF CONTRIBUTIONS/DONATIONS - PRIVATE ENTITIES
(b)
(c)
1
No.
Name and Address
(d)
2
Nationality
(e)
Total Contributions
Type of Contribution3
1
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
2
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
3
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
4
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
5
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
6
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
7
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
8
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
9
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
10
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
11 Other
(aggregate of all contributions
which are individually below P100,000.00)
- by nationality
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
(Note: Please use additional forms/sheets or extend the fields for disclosure if necessary)
TOTAL CONTRIBUTIONS/DONATIONS
-
1
A contributor or donor includes individuals, partnerships, corporations, associations, trusts and organizations.
2
If supranational organization, indicate place of principal office or domicile.
3
Contributions or donations reportable on the Schedule are contributions, donations, grants, bequests, devises, and gifts of
money or property, amounting to P100,000.00 or more from each contributor or donor.
Page 2 of 11
Name of Foundation
SEC Registration No.:
Period:
S1-A
SCHEDULE OF CONTRIBUTIONS/DONATIONS - PRIVATE ENTITIES
Name of Foundation/Organization:
SEC Registration No.
For the year ended:
S1-A
(a)
No.
Noncash Property
(b)
Description of Noncash Property Given
(c)
Fair Market Value (or estimate)
(d)
Date received
1
2
3
4
5
6
7
8
9
10
(Note: Please use additional forms/sheets or extend the fields for disclosure if necessary)
TOTAL NONCASH PROPERTY
-
Page 3 of 11
Name of Foundation
SEC Registration No.:
Period:
S2
SCHEDULE OF CONTRIBUTIONS/DONATIONS - GOVERNMENT ENTITIES
Name of Foundation/Organization:
SEC Registration No.
For the year ended:
S2
(a)
No.
1
SCHEDULE OF CONTRIBUTIONS/DONATIONS Government Officers/Officials or Government Offices, Agencies or Instrumentalities
(b)
(c)
1
Government Unit and Address
Government Unit and Address1
Government Unit and Address1
(d)
2
Authorizing Officer
Authorizing Officer
Authorizing Officer
(e)
Total Contributions
Total Contributions
Total Contributions
Type of Contribution
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
2
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
3
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
4
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
5
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
6
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
7
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
8
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
9
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
10
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
11
Cash
Non/Cash
(Complete Part II if there is
a noncash contribution)
(Note: Please use additional forms/sheets or extend the fields for disclosure if necessary)
TOTAL CONTRIBUTIONS/DONATIONS
-
1
List down the name and address of the government office, agency or unit and specify its chapter, regional or extension office, if applicable.
Identify the name of responsible officer/official or authority approving the donation/contribution to the foundation
2
Page 4 of 11
Name of Foundation
SEC Registration No.:
Period:
S2-A
SCHEDULE OF CONTRIBUTIONS/DONATIONS - GOVERNMENT AND ITS INSTRUMENTALITIES
Name of Foundation/Organization:
SEC Registration No.
For the year ended:
S2-A
(a)
No.
Noncash Property
(b)
Description of Noncash Property Given
(c)
Fair Market Value (or estimate)
(d)
Date received
1
2
3
4
5
6
7
8
9
10
(Note: Please use additional forms/sheets or extend the fields for disclosure if necessary)
TOTAL NONCASH PROPERTY
-
Page 5 of 11
Name of Foundation
SEC Registration No.:
Period:
S3
SCHEDULE OF MISCELLANEOUS INCOME
Name of Foundation/Organization:
SEC Registration No.
For the year ended:
S3
Schedule of Miscellaneous Income
No.
Description of Income
1
2
Dividend Income
Investee # 1
Investee # 2
Investee # 3
Investee # 4
4
Proceeds from sale of Property, Plant or Equipment
PPE # 1
PPE # 2
PPE # 3
PPE # 4
5
Gains on Forex Transactions
Cash and Cash Equivalents
Receivables
Payables
Others
6
Refunds / Reimbursements
Nature # 1
Nature # 2
Nature # 3
Nature # 4
7
Fair Value Gains on Trading Securities
Trading Securities # 1
Trading Securities # 2
Trading Securities # 3
Trading Securities # 4
8
Amount
Rental Income
Lessee # 1
Lessee # 2
Lessee # 3
Lessee # 4
3
Particulars
Interest Income from bank deposits (indicate FCDU* if applicable)
Bank # 1
Bank # 2
Bank # 3
Others
Other sources not included above
(Note: Please use additional forms/sheets or extend the fields for disclosure if necessary)
TOTAL MISCELLANEOUS INCOME
-
*Foreign Currency Deposit Unit
Page 6 of 11
Name of Foundation
SEC Registration No.:
Period:
S4
SCHEDULE OF OTHER INCOME
Name of Foundation/Organization:
SEC Registration No.
For the year/s ended:
S4
No.
1
Schedule of Other Income / Other Sources of Funds
Project Name (and description)
E.g. Annual Garage Sale / Fund-raising Activity
Period Covered
Amount
2
3
4
5
6
7
8
9
(Note: Please use additional forms/sheets or extend the fields for disclosure if necessary)
TOTAL OTHER INCOME
-
Page 7 of 11
Name of Foundation
SEC Registration No.:
Period:
S5
OTHERS
Name of Foundation/Organization:
SEC Registration No.
For the year/s ended:
S5
Schedule of Other Sources of Funds other than listed in S1,S2,S3 and S4.
(a)
No.
1
(b)
Nature
Borrowings (Name of Lender and Address)
(c)
(d)
Particulars
Amount
Term to Maturity
2
3
4
5
6
7
8
(Note: Please use additional forms/sheets or extend the fields for disclosure if necessary)
TOTAL OTHER SOURCES
-
Page 8 of 11
AF
Name of Foundation:
SEC Reg. No.:
Period:
STATEMENT OF APPLICATION OF FUNDS
PROJECT INDEX
A3
A2
(PROJECT
(PROJECT
TITLE)
Particulars
A1
TITLE)
O1
O2
(PROJECT
(PROJECT
(PROJECT
TITLE)
TITLE)
Gen. Admin
OPEX
TITLE)
TOTAL
Allocated Budget
CAPEX / Inventory:*
Asset Class #1
Asset Class #2
Asset Class #3
Asset Class #4
Asset Class #5
Inventory #1
Inventory #2
Inventory #3
Inventory #4
Subtotal
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
OPEX Breakdown:
Consultants
Service Contracts
Travels & Transportation
Training
Meetings & Conferences
Supplies
Communications
Courier and Freight
Utilities
Bank Charges
Permits and Licenses
Donations
Repairs & Maintenance
Depreciation
Promotions
Miscellaneous
Subtotal
TOTAL Applications
(Note: Please use additional forms/sheets or extend the fields for disclosure if necessary. Refer further to Instructions Sheet)
*Asset Class pertains to grouped items of asset per accounting policy identified in line with its nature, estimated useful life or use.
(E.g. Office Equipment are identified in an asset class separate from Land or Building)
Page 9 of 11
Name:
Reg. No.:
AF-A
Period:
ACCOMPLISHED/ON-GOING PROJECTS/PROGRAMS
PROJECTS BENEFICIARIES
Accomplished (A)
Officer-inCharge
Address/
Contact #
Project
Location
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10
A11
A12
A13
A14
Ref
CERTIFICATE OF
EXISTENCE
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10
A11
A12
A13
A14
On-going (O)
Officer-inCharge
Address/
Contact #
Project
Location
O1
O1
O2
O2
O3
O3
O4
O4
O5
O5
O6
O6
O7
O7
O8
O8
O9
O9
O10
O10
O11
O11
O12
O12
O13
O13
(Note: Please use additional forms/sheets or extend the fields for disclosure if necessary)
Page 10 of 11
Name:
Reg. No.:
CIB
Period:
SCHEDULE OF BANK DEPOSITS
Account No.
Depository Bank (Branch)
Bank Address
Currency
Amount in PHP
(Note: Please use additional forms/sheets or extend the fields for disclosure if necessary)
Page 11 of 11
INSTRUCTIONS IN THE PREPARATION
OF SWORN STATEMENT OF SOURCES AND APPLICATION OF FUNDS
1 The Sworn Statement of Sources and Application of Funds is practically a statement accounting for the change in
FUND BALANCE from the beginning to the end of the current fiscal period. It does not account for the change in
CASH BALANCE. The said statement should reconcile with the financial statement for even period.
2 Please do not leave any space blank. Disclosures may be made in the statement preferably in the form of a
sentence. N/A is discouraged.
3 A1 stands for Accomplished Project No. 1, A2 stands for Accomplished Project No. 2, so forth and so on.
O1 stands for On-Going Project No. 1, O2 for On-Going Project No.2, so forth and so on.
4 S1 Stands for Source of Funds No.1, and so on whereas AF stands for Schedule of Application of
Funds.
5 Sources and Application of Funds should be itemized by indicating the names and addresses of the Donors and
Payees identifying their nationalities, the amount of contribution/donation and whether such amount is received
in cash or as a non-cash contribution/donation. Non-cash receipts should disclose the Description of the noncash
property, fair market value/best estimate and the date of receipt.
Please refer closely to footnotes provided per proforma schedule.
6 Reporting Application of Funds should be on a project basis.
7 Please report/indicate the exact name or title of the project/activity of the foundation. All certifications of
project existence should likewise indicate the exact title or name of the project/activity as reported in the
Sworn Statement.
