Republic of the Philippines )

_____________________ ) SS.

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

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 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 ___________________.

NOTARY PUBLIC

Doc. No. _____

Page No. _____

Book No. _____

Series of _____.