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:
- That my husband/wife was employed as _______________________________at the Commission on Audit prior to his/her death on __________________________;
- That t I am applying for Survivorship benefits effective _______________________;
- Pls. check [√]appropriate box
- That I am executing this affidavit to attest to the truth of the foregoing facts.
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: _______________________________
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 _____