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    Affidavit for Anti-Graft and Corrupt Practices (Survivorship)


    Republic of the Philippines )
    _____________________ ) SS.
    x- - - - - - - - - - - - - - - - - - - - - x


    AFFIDAVIT FOR ANTI-GRAFT AND CORRUPT PRACTICES (RA 3019)
    (Survivorship)



    I, _______________________________, of legal age, Filipino, widow/widower and presently residing at ___________________________ having been duly sworn to in accordance with law, depose and say:

    1. That I am the widow/widower of _______________________________________ who was an employee of the Commission on Audit (COA) until his/her death on ______________________.

    2. That I have applied for GSIS survivorship benefits as a surviving spouse effective _____________________

    3.   That to the best of my knowledge, my husband/wife has no administrative/criminal investigation/charges against him/her for any offense, defined or penalized under RA 2019, otherwise known as the Anti-Graft and Corrupt Practices Act, as amended, and under the provisions of the Revised Penal Code on Bribery; 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 set my hand and affixed my signature this _________ day of ______________, 20 ______  at _______________________.



    _______________________________
    Affiant


    SUBSCRIBED AND SWORN TO BEFORE ME this _______ day of ___________, 20 ______, affiant exhibited to me his Government Issued ID __________ No. ______________ issued at __________________ on ___________________.


    Doc. No. _____
    Page No. _____
    Book No. _____
    Series of _____.



    NOTARY PUBLIC


    Source: coa.gov.ph

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