OMNIBUS SWORN STATEMENT

Republic of the Philippines )

City of Butuan ) S.S.

AFFIDAVIT

I, MA. ELMA ACUSAR, of legal age, Filipino, married, and a resident of 096, J.C. Aquino
Avenue, Butuan City after being sworn to in accordance with law, depose and state that:

1. I am the sole proprietor of New LA Enterprises with business address at 096,

J.C. Aquino Avenue, Butuan City;

2. New LA Enterprises has paid the Business Tax, Fees and Charges for the
operation of business for the year 2020 (Please refer to the attached Annex “A”);

3. New LA Enterprises has Certificate of PHILGEPS Registration (Platinum

Membership) issued on November 22, 2019 (Please refer to the attached Annex
“B”);

4. As the owner and sole proprietor of New LA Enterprises, I have full power and
authority to do, execute and perform any anf all acts necessary to represent it
in the bidding for Supply and Delivery of Chain Hoist (Chain Block) for
LARPIS Pumping Station use:

a. 1 set Chain Hoist (Chain Block) 10 tons;

b. 6 falls loas chain; and
c. Lift 60 feet with accessories

5. New LA Enterprises is not “blacklisted” or barred from bidding by the

Government of the Philippines or any of its agencies, officies, corporations, or
Local Government Units, foreign Government/foreign or international
financing institution whose blacklisting rules have been recognized by the
Government Procurement Policy Board;

6. Each of the documents submitted in satisfaction of the bidding requirements is

an authentic copy of the original, complete, and all statements and information
provided therein are true and correct;

7. Ma. Elma Acusar is authorizing the Head of Procuring Entity or it’s duly
authorized representative to verify all the documents submitted;

8. I am not related to the Head of Procuring Entity, members of the Bids and
Awards Committee (BAC), the Technical Working Group, and the BAC
Secretariat, the head of the Project Management Office or the end-user unit,
and the project consultants by consanguinity or affinity up to the third civil
degree;

9. New LA Enterprises complies with existing labor laws and standards;

10. New LA Enterprises is aware of and has undertaken the following

responsibilities as a Bidder;

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 a. Carefully examine all of the Bidding Documents;
b. Acknowledge all conditions, local or otherwise, affecting the
implementation of the Contract;
c. Made an estimate of the facilities available and needed for the contract to
be, if any; and
d. Inquire or secure Supplemental/Bid Bulletin (s) issued for the Supply and
Delivery of Chain Hoist (Chain Block);

11. Ma. Elma Acusar did not give or pay directly or indirectly, any commission, or
any form of consideration, pecuniary or otherwise, to any person or official,
personnel or Representative of the government in relation to any procurement
project or activity.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of

_________________________ in Butuan City, Philippines.

MA. ELMA ACUSAR

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this ____ day of

_________________________ in Butuan City, Philippines by the Affiant who presented his
Driver's License No. K01-01-044751, valid until February 13, 2024, issued in Butuan City,
Philippines.

Doc. No. ______;

Page No. ______;
Book No. IV
Series of 2020.

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