AFFIDAVIT OF UNDERTAKING

I, __________________________ , married, of legal age, resident of ______________, a

bonafide pensioner of the Philippine National Police, after being sworn to in accordance with the law,
do hereby depose and state that:

a) I am a pensioner of the Philippine National Police/Integrated National Police since

_____________,with the pension amount of _________________;

b) Consistent with the requirements of the Philippine National Police Retirement and Benefits
Administration Service (PRBS), I hereby bind and oblige myself to update my retirement
records during my birth month;

c) In case of physical incapacity, illness or medical condition which will prevent my person from
performing the aforestated obligation, I hereby appoint and constitute my legal wife
______________________________________ or my daughter/son (in case of unmarried
retiree, state the name of nearest kin) _____________ as my lawful attorney-in-fact to transact
business relating to my status as a PNP/INP pensioner with PRBS;

d) Consistent with the intent embodied in this instrument, my designated attorney-in-fact shall
inform the PRBS of any circumstances that will happen to my person. Further they will be the
custodian of my pension ATM Card and passbook account with the obligation of managing the
same with due regard to its nature as government funds and subsequent civil and criminal
liabilities under the pertinent provisions of the New Civil Code of the Philippines and Republic
Act 8484;

e) Further, I hereby acknowledge the authority of the PNP to place my pension account on “tag
and hold” status in the event of my failure to update my retirement records during the period
provided under the rules or non-reporting by my designated attorney-in-fact of any untoward
circumstance that will happen to my person.

Done this ____ day of _______, ______, in _________ Philippines.

____________
(Affiant)
Our conformity:

1.________________________
(Name)
Relationship ________________
Contact Number _____________
Complete Address ___________

2. _________________________
(Name)
Relationship _________________
Contact Number ______________
Complete Address ____________

(N.B. This Affidavit shall not be accepted by PRBS if not notarized)

Sworn and subscribed to before me this ______ day of ________, 2020, ___________________Philippines.

NOTARY PUBLIC
Page No:______
Document No:___
Book No:_____
Series of 2020