Republic of the Philippines

______________ ) S.S.

AFFIDAVIT OF PENDENCY/NON-PENDENCY OF ADMINISTRATIVE/ CRIMINAL

CASE

I, __________________________________, of legal age, Filipino, with permanent

address at _________________________________________________, after having been duly
sworn to in accordance with law, hereby voluntarily depose and say:

1. I am currently/formerly employed as
________________________________ in the Commission on Audit;

2. That I am applying for optional/compulsory retirement to take effect/effective

on _______________________;

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 case Criminal case

Nature/specific offenses charged: _________________________________

(specify)

4. That I am executing this affidavit to attest to the truth of the foregoing facts
for the expeditious processing of my retirement benefits.

IN WITNESS HEREOF, 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/her Government Issued ID
__________with No._________________ issued at ____________________ on
____________________.

Doc. No. ________

Page No. ________
Book No. ________
Series of ________ NOTARY PUBLIC