Republic of the Philippines)
Province of ____________________) S.S.
City/Municipality of _____________)
x – – – – – – – – – – – – – x
I, _____________, Filipino, of legal age, (single / married / widow), and a resident of _____________, Philippines, after being sworn to in accordance with law, depose and state:
That I have been elected by the subscribers of the __Name of Corporation__, Inc. as Treasurer thereof, to act as such until my successor has been duly elected and qualified in accordance with the by-laws of the corporation, and that as such Treasurer, I hereby certify under oath that at least twenty-five (25%) percent of the authorized capital stock has been subscribed and at least twenty-five (25%) percent of the subscription has been paid and received by me in cash for the benefit and credit of the corporation.
That one of the subscribers, _____________, is an (U.S. citizen), and (he/she) has subscribed to _____________ shares with a total value of __________________________ (P_____________) and has fully paid his subscription in Philippine Currency which amount was duly received by me to the benefit and credit of the corporation.
This is also to authorize the Securities and Exchange Commission (SEC) and Bangko Sentral ng Pilipinas (BSP) to examine and verify the deposit in the __Name of Bank__ (_____________ Branch) in my name as Treasurer-in-Trust for __Name of Corporation__, INC. in the amount of __________________________ (P_____________) representing the paid-up capital of the said corporation which is in the process of incorporation. This authority is valid and inspection of said deposit may be made even after the issuance of the Certificate of Incorporation to the corporation. Should the deposit be transferred to another bank prior to or after incorporation, this will also serve as authority to examine the pertinent books and records of accounts of the corporation as well as supporting papers to determine the utilization and disbursement of the said paid-up capital.