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 the 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