Republic of the Philippines )

City/Mun. of __________) S.S.

x-----------------------x

AFFIDAVIT

I, _________________, of legal age, single/married/widow, Filipino citizen, and presently residing at _____________________, after having been duly sworn to in accordance with law, do hereby depose and say:

1. That I was formerly employed as ____________________________ in the ________________________________________;

2. That I am retiring under RA1616/PD 1146, RA660 effective __________________.

3. That there is no administrative 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; 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 hereunto set my hand this ____ day of ___________ 20____ in ____________, _____________, Philippines.

___________________________________

Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of _________ at ________________ affiant exhibited to his/her competent evidence of identity by way of _________________ issued on __________________ in _______________, Philippines.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;