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:
- That my husband/wife was employed as _______________________________at the Commission on Audit prior to his/her death on __________________________;
- 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 _______________________.