Republic of the Philippines)

City of _______________ ) S.S

SWORN STATEMENT

I, _________________,  of legal age, single/married with postal and residence address at

_________________________________________, after being duly sworn to in accordance with
law, hereby depose and state that:

1. I am an employee of the Commission on Audit assigned as ____________ at the

____________;

2. There is no complaint(s) against the undersigned pending with the Civil Service
Commission, Office of the Ombudsman, any Prosecutor’s Office, Department of Justice,
or any regular courts or the Court of Appeals and the Supreme Court; or pending
administrative case with the Commission on Audit or any Administrative body; and

3. I am executing this sworn statement to lend to the veracity of the foregoing statement and
for whatever legal purpose or purposes that it may serve;

AFFIANTS FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ of ____________

at_____________, Philippines.

________________
Affiant

SUBSCRIBED AND SWORN to before me this____ of _________ by affiant exhibited

to me his/her ____________ issued at _____________ City on ________________.

Doc. No. ______;
Page No. ______;
Book No.______;
Series of  ______.