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Sworn Statement - Sample Goods

This sworn statement details that the affiant owns a pharmacy that was supplied by 999 Seth Pharmaceuticals. However, the affiant received a statement of accounts verification from 999 Seth listing purchases the affiant claims were not ordered. The affiant believes the 999 Seth sales representative encoded fraudulent transactions in the affiant's account to embezzle money. The affiant signed this sworn statement to attest to the facts presented.

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Mark Bati
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187 views1 page

Sworn Statement - Sample Goods

This sworn statement details that the affiant owns a pharmacy that was supplied by 999 Seth Pharmaceuticals. However, the affiant received a statement of accounts verification from 999 Seth listing purchases the affiant claims were not ordered. The affiant believes the 999 Seth sales representative encoded fraudulent transactions in the affiant's account to embezzle money. The affiant signed this sworn statement to attest to the facts presented.

Uploaded by

Mark Bati
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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REPUBLIC OF THE PHILIPPINES )

____________________________) S.S

SWORN STATEMENT

I _________________________, both of legal age, Filipino Citizen, and are resident of


___________________________________________________________________, after having been
duly sworn to, hereby depose and say:

 That I am the owner of ________________________, which is located at


_________________________________________________________;

 That 999 Seth Pharmaceutical Inc. is one of our suppliers of pharmaceutical products
here in ___________;

 That the 999 Seth’s salesman here who used to deal with us was
_______________________;

 That sometime in _______________, I received a Statement of Accounts Verification


letter dated _____________ from 999 Seth Pharmaceutical Inc. and informed us of our
supposed outstanding balances in the amount of _____________.

The details of the said Statement of Accounts Verification are as follows

Name of Client Purchase Order Date Amount

 That I was baffled because the said transaction stated in the Statement of Accounts
Verification were not ordered by me nor my staff, that ____________________ encoded
the said transaction in my account to embezzle money thru my account;

 That I am executing this sworn statement to attest to the truth and fact of the foregoing; it
is likewise being executed for such other purpose/s that it may serve.

IN WITNESS WHEREOF, we have hereunto set our hands this _____ day of ______ 2020 in
_______________, Bulacan.

_______________________
Affiant
ID:________________
ID Number: _______________

______________________
Witness

SUBSCRIBED AND SWORN to before me in the _____________, this ____day of ____2021 by


affiants who exhibited to me their identification cards, known to me and to me known to be the same
persons who personally signed before me the Sworn Attestation and acknowledged that they executed
the same.

NOTARY PUBLIC
Doc No._____:
Page No.____:
Book No.____:
Series of 2021

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