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    Affidavit of Pendency/Non-Pendency of Administrative/Criminal Case (Survivorship)


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


    AFFIDAVIT OF PENDENCY/NON-PENDENCY OF 
    ADMINISTRATIVE/CRIMINAL CASE (Survivorship)


    I, _______________________________, of legal age, Filipino, widow/widower and with permanent address at ___________________________ after having been duly sworn to in accordance with law, hereby voluntarily depose and say:

    1. That my husband/wife was employed as _______________________________at the Commission on Audit prior to his/her death on __________________________;

    2. That t I am applying for Survivorship benefits effective _______________________;

    3. Pls. check [√]appropriate box

    4.   That there is no pending administrative or criminal case filed against me in any forum

        That there is a pending case against me, details of which are as follows:

         Administrative                   Criminal

      Nature/specific offenses charged: _______________________________

    5. That I am executing this affidavit to attest to the truth of the foregoing facts.
    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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