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REPUBLIC OF THE PH I LIPPIN ES
=fr PH I LI PPI N ES STATISTICS AUTHORITY
\_' BACOI,C PIL'PINAS
SWORN DECLARATION/IDENTIFICATION OF RELATIVES
(Purcuant to the Policy on Nepotism under the Updated Guidelines
on Recrui0nent aN tanagement of Contract of Seruice Worters)
l, Mr.Ms of legal age, presently residing
at
I dc, hereby declare that I do not have any relatives
I d,r hereby dechre/rdentifr the following as my relative/s or rnember/s of my family within the third
d{}gree either of consanguinity or of affnity who isr'are connected/employed in the Philippine
SraHhs Authority as either empbye€/conhac{ of service worker/iob order worter
trlAffi RELATIONSHIP DESIGI{ATION PI.ACE
OF ASSIGNTENT
1.
2.
3.
4.
5.
It is hereby understood that "relative' or Tamily membef within the third degree either of
consarrguinity or of affinity refers to the follo ing:
Coruenguinity AfEnity
(includ€s andiviluals relat€d by blood) (indudes the individuab Spouse and Relaled to the
Spouse)
Firlt Dsorlo SGcond Dogrse Third Degreo FiEt Degrse Second Degllo Third Dogrse
Father and Motl€( Baothor ard SiBtrr Urde ard A.rt SpoGe B.oBEa+*ar Uade-in-larY
ard Sister+r-lel Arntir.bw'ld
S on ard Dat{hter Gralllffil€aand Ne9lw aixt t{e.e FattEr-in+rY rd GradBEri a* Ite9tE*il-law ard
C{ard,ndEr iiloltsi|.law ard GrdldndEr- Nirca-arLlar
i,
Gmndsm and Soniniaw o. G.andldFin-laa, -d
G.addaug}le. Daugh&.nHaw G.urddsrrghbdn-
hw
Also, I declare thd
[ ] I dc' not have a relative prevbusly employed in te Philiffie Stailisths Authority that has retired, died
or became incapacitded (permanent or total disability).
[] lar a relativeof name of employee) who has
retired/died/became incapacitated (Plea* underline).
I am his,/her spouse/soddaughter/brdrer/sister (Pease urrCerline)
I declare under oath Olat thb document has been accomplbhed by rne, and is a true, conect and
compbte statement pursuant to the provisions of pertiner larvs and agency rules and regulations.
I also ,:uthorize the agency head/authorized representative to verifffualiJate the contents stated herein.
I trust t hat this information shall remain confidential.
Signed at on
(htq
Printed Name and Signatur€
PSA Complex, East Av6nue, Diliman, Quezoa City, Philippines 1101
KJffi.ffi
Lr,rl *c.E
Telepho,E: (632) 8908-5267
www.psa.gov.ph
