Republic of the Philippines )
___________________________ ) SS.
x- - - - - - - - - - - - - - - - - - - - - x
OF ADMINISTRATIVE/CRIMINAL CASE
I, _______________________________, of legal age, Filipino, with permanent address at _________________________________________________, after having been duly sworn to in accordance with law, hereby voluntarily depose and say:
1. That I am currently/formerly employed as ________________________________ in the Commission on Audit.
2. That I am applying for optional/compulsory retirement to take effect/effective on _______________________;
3. Pls. check [√] appropriate box
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:
Nature/specific offenses charged: _______________________________
4. That I am executing this affidavit to attest to the truth of the foregoing facts for the expeditious processing of my retirement benefits.
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 _____