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 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 ______;