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

Republic of the Philippines )

_____________________ ) SS.

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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


  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: _______________________________


4. 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