Republic of the Philippines )
___________________________ ) SS.
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AFFIDAVIT FOR ANTI-GRAFT AND CORRUPT PRACTICES (RA 3019)
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 _______________________.
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 _____