Republic of the Philippines )
City/Mun. of __________
I, _________________, of legal age, single/married/widow, Filipino citizen, and presently residing at _____________________, after having been duly sworn to in accordance with law, do hereby depose and say:
1. That I was formerly employed as ____________________________ in the ______________________________________________;
2. That I am retiring under RA1616/PD 1146, RA660 effective __________________.
3. That there is no administrative criminal investigation against me for any offense, defined or penalized under RA3019, otherwise known as the Anti- Graft and Corrupt Practices Act, as amended and under the provisions of the Revised Penal Code; and
4. That I am executing this affidavit to attest to the truth of the foregoing facts or assertation in compliance with COA Memorandum No. 451 dated March 6, 1973.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my signature this ____ day of _______ 2014 at ______________, Philippines.
SUBSCRIBED AND SWORN to before me this ____ day of ______ 2014 in _________, Philippines,
affiant exhibiting to me his/her competent evidence of identity by way of _______________ issued at ___________ on ________________.
Doc No. : _____
Page No.: ______
Book No.: ______
Series of 2014 Notary Public