Republic of the Philippines )
_____________________ ) SS.
x- – – – – – – – – – – – – – – – – – – – – x
I, _______________________________, of legal age, Filipino, __________________ and a resident of ___________________________ after having been duly sworn to in accordance with law, hereby voluntarily depose and say:
- 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.
- I am applying for Terminal Leave on his/her behalf effective _______________________________.
- That pre-audit of financial transaction of national government agencies, among others, has been lifted per COA Circular 2011-002 dated July 22, 2011;
- 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;
- 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
- 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.