DSWD-SB-GF-127 | REV 01 | 04 FEB 2025
ANNEX N.
DECLARATION FORM
APPLICATION FOR REGISTRATION, LICENSING AND ACCREDITATION
I, [Name of Affiant], of legal age, [Civil Status], [Nationality], and residing at [Address of
Affiant], after having been duly sworn in accordance with law, do hereby depose and state
that:
1. [Select one, delete the other:]
[If the head of the agency:] I am the head of [Name of SWDA] with office address
at [address of SWDA];
[If Authorized representative:] I am the duly authorized and designated
representative of [Name of SWDA] with office address at [address of SWDA];
2. [Select one, delete the other:]
[If the head of the agency:] As the agency head of [Name of SWDA], I have full
power and authority to do, execute and perform any and all acts necessary to
participate, submit the documents, and sign and execute the application for
Registration, Licensing and/or Accreditation of [Name of SWDA] as shown in the
attached [state title of attached document showing proof of authorization (e.g.,
duly notarized Secretary’s Certificate, Board/Partnership Resolution, or Special
Power of Attorney, whichever is applicable;)];
[If Authorized representative:] I am granted full power and authority to do,
execute and perform any and all acts necessary to participate, submit the
documents, and sign and execute the application for Registration, Licensing
and/or Accreditation of [Name of SWDA], as shown in the attached [state title of
attached document showing proof of authorization (e.g., duly notarized
Secretary’s Certificate, Board/Partnership Resolution, or Special Power of
Attorney, whichever is applicable;)];
3. [Name of SWDA] is not “blacklisted” or barred from applying for Registration,
License, and Accreditation Certificates with the Department of Social Welfare
and Development (DSWD) as defined and provided under DSWD MC 18 series
of 2024 or the Omnibus Guidelines on the Regulation of Social Welfare and
Development Agencies (SWDAs) and their Social Welfare and Development
(SWD) Programs and Services;
4. [Name of SWDA] is not blacklisted to do transactions with the Government of the
Philippines or any of its agencies, offices, corporations, or Local Government
Units (LGU), foreign government/foreign or international financing institution
whose blacklisting rules have been recognized by the Government Procurement
Policy Board, by itself or by relation, membership, association, affiliation, or
controlling interest with another blacklisted person or entity as defined and
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DSWD Central Office, IBP Road, Batasan Pambansa Complex, Constitution Hills, Quezon City, Philippines 1126
Website: http://www.dswd.gov.ph Tel Nos.: (632) 8 931-8101 to 07 Telefax: (632) 8 931-8191
DSWD-SB-GF-127 | REV 01 | 04 FEB 2025
provided for in the Uniform Guidelines on Blacklisting;
5. [Name of SWDA] undertakes that, in the event that it receives any donation or
payment from any person or business related to the tobacco industry, [Name of
SWDA] shall not allow any form of promotion, advertisement, nor sponsorship of
any of tobacco products, including any item, material, tangible or intangible that
would identify or associate such donation in cash or in-kind to the tobacco
company, or its manufacturer or wholesaler, or any person, interset group,
advocacy organization, law firm, advertising agency or other business
organization that represents the interest of the tobacco industry.
6. Each of the documents submitted in satisfaction of the registration, licensing
and/or accreditation requirements is an authentic copy of the original, complete,
and all statements and information provided therein are true and correct;
7. [Name of SWDA] is authorizing the DSWD or its duly authorized
representative(s) to verify all the documents submitted and is authorized to
inspect the premises of the office as part of its monitoring activities;
8. [Name of SWDA] has no unliquidated funds and it is free from any financial
liability/obligation from past and current collaborative partnerships with the
DSWD that involve a transfer of funds;
9. [Name of SWDA] shall keep a record of all social development and/or welfare
activities they handle in accordance with RA No. 10847;
10. [If private agencies that are planning to engage:] [Name of SWDA] shall operate
within six (6) months upon issuance of its Certificate of Registration and License
To Operate (CRLTO) from the DSWD; and
11. [Name of SWDA] is not, in any way, connected with commercial importation of
used or pre-owned clothing and is not importing any adulterated or misbranded
food or goods for human consumption or any adulterated or misbranded drug in
violation of relevant laws and regulation.
12. All personal data, as defined under the Data Privacy Act of 2012 and its
implementing rules and regulations, along with account transaction information or
records with the DSWD may be processed, profiled, or shared to requesting
parties or for the purpose of any court, legal process, examination, inquiry, and
audit or investigation of any authority.
Furthermore, I [Name of Affiant], under penalty of perjury, certify that all information
provided in my application is true and correct to the best of my personal knowledge and is
based on authentic records submitted to the DSWD. Supplying false or misleading
information or producing falsified documents shall be grounds for appropriate administrative
and criminal actions against me, including the revocation of the issued
registration/license/certificate.
[SIGNATURE OVER PRINTED NAME OF THE HEAD OF THE AGENCY
OR ITS AUTHORIZED REPRESENTATIVE]
________________________________________
Affiant
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DSWD | RSIDG | SB
DSWD-SB-GF-127 | REV 01 | 04 FEB 2025
Subscribed and sworn to before me, a Notary Public in and for [city], affiant exhibiting to me
his/her [competence of identity] issued at [insert] and expiring on [insert], who who was
identified by me through competent evidence of identity to be the same person who
presented the foregoing instrument and signed the instrument in my presence, and who
took an oath before me as to such instrument.
Witness my hand and seal this ___ day of ______, ________
[INSERT NOTARIAL CERTIFICATE]
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DSWD | RSIDG | SB
