Republic of the Philippines )
__________________________ ) SS.
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AFFIDAVIT OF UNDERTAKING FOR TERMINAL LEAVE (Survivorship)
I, _______________________________, of legal age, Filipino, __________________ and a resident of ___________________________ after having been duly sworn to in accordance with law, hereby voluntarily depose and say:
1, That I am the __________________ of the late ________________________ who passed away on ___________________ at _____________________________ and that at the time of his/her death was presently employed in the Commission on Audit.
2. I am applying for Terminal Leave on his/her behalf effective ___________________________________.
3. That pre-audit of financial transaction of national government agencies, among others, has been lifted per COA Circular 2011-002 dated July 22, 2011;
4. That should it appear in post-audit there was overpayment in the money value of his/her terminal leave benefits, I am willing to make refund of any excess amount thereon;
5. That on the other hand, it will appear in post-audit that he/she was underpaid in his/her terminal leave benefits, it is understood that the Commission on Audit shall likewise pay him/her the difference of the amount corresponding to the underpayment; and
6. That I am executing this affidavit to attest to all above facts.
IN WITNESS WHEREOF, I have hereunto signed my name below 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 _____