REPUBLIC OF THE PHILIPPINES

NAME OF CITY/MUNICIPALITY)S.S.

AFFIDAVIT OF UNDERTAKING

I, _______________________________________, of legal age, married/single/separated/widowed,

Filipino and a resident ___________________________________________________________________________________,
after having been duly sworn to in accordance with law hereby depose and state:

1. That I am currently working at the (LGU Name) as (Position).

2. That I intend to travel to (country of destination) on (travel date from and to).

3. That I am facing the following cases, to wit:

a. (Case Number, Title, Venue); and

b. (Case Number, Title, Venue).

4. That I will face the foregoing charges until their final disposition;

5. That I hereby undertake to return to the Philippines and report to office

immediately after my travel date; and

That I am executing this affidavit to attest to the truth of all foregoing declarations and
for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of _______________,
________, in the ______________________________, Philippines

________________________
Affiant

SUBCRIBED AND SWORN to before me this ________________________________ day of

_______________ in _____________________. Affiant exhibited to me his/her Government Issued ID No.
____________________ issued on _______ at _____________, ________________________________.

NOTARY REPUBLIC

Doc No. _____________;

Page No. ____________;
Book No. ___________;
Series of. ___________.