ANNEX “C”

C.E. Form No. 39

Republic of the PHilippines

COMMISSION ON ELECTIONS

_______________________________________
(City/Municipality, District, Province)

______________________________
(Region)

SYNCHRONIZED BARANGAY AND SANGGUNIANG KABATAAN ELECTIONS

OCTOBER 28, 2013

INSTRUCTIONS:

Prepare two (2) copies of this form. Attach one (1) copy to the Minutes of Voting and one copy to the
challenged voter or affiant.

OATH OF VOTER CHALLENGED FOR ILLEGAL ACTS

I, ________________________________________________________________, a resident of
_______________________________________________________________________________ and a
registered voter of Precinct No. ___________, Barangay
______________________________________, City/Municipality ________________________,
Province ______________________ do solemnly swear (or affirm) that I have neither received
nor expected to receive, have not paid, offered or promised to pay, nor I have contributed,
offered or promised to contribute money or anything of value as consideration for my vote or
for the vote of another; that I have not made or received any promise to influence the giving
or withholding of any vote; and that I have neither made any bet nor am I directly or
indirectly interested in any bet which depends upon the result of th election.

IN WITNESS WHEREOF, I have hereunto set my hand this ______ day of _______________, 2013
in the City/Municipality of ___________________ Province of ______________________________,
Region _______________, Philippines.

_______________
________________________________
Affiant
(Signature over Printed Name)

_________________________________)
(City/Municipality)
_________________________________) S.S.
(Province)

SUBSCRIBED AND SWORN to before me this _____________________________________________

day of __________________________, 2013 in the above‐stated
‐stated place.

_____________________
________________________________
Chairman/Member,Board of Election
Tellers/Special Board of Election Tellers
((Signature over Printed Name)