Republic of the Philippines )

_____________________ ) SS.

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AFFIDAVIT FOR ANTI-GRAFT AND CORRUPT PRACTICES (RA 3019)

I, _______________________________, of legal age, Filipino, single/married/widow/widower and a resident of ___________________________ 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 retiring/ under RA 1616/PD 1146/RA 8291 to take effect/effective on _______________________.

3. That there is no administrative or criminal investigation against me for any offense, defined or penalized under RA 3019, 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 _______________________.

_______________________________

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