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

Affidavit COA Forms Government Forms


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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