Republic of the Philippines

______________________

AFFIDAVIT OF UNDERTAKING
(Survivorship)

I, _______________________, of legal age, Filipino, single/married/widow/widower and a

resident of _______________________________________, after having been duly sworn to in
accordance with law, hereby voluntarily depose and say:

1. That I am the ________________ of the late _______________________ who was

an employee of the Commission on Audit (COA) until his/her death on
_____________________;

2. That we are applying for Survivorship Benefits effective ____________________;

3. That his/her terminal leave benefits is not sufficient/has no terminal leave benefits
to cover his/her COA bill from the Commission amounting to _________________
and loan obligations from the ________________________________ amounting to
(Financial Institutions)
__________________;

4. That we will pay his/her obligations to the _____________________ immediately

after receipt of his Survivorship Benefits from GSIS; and

5. That I am executing this affidavit to attest to all the above facts.

IN WITNESS HEREOF, I have hereunto signed my name below this ________ day of
_____________,20______ at ________________.

___________________
(Affiant)

Witness:

____________________

SUBSCRIBED AND SWORN TO BEFORE ME this _______ day of _________

___________,20 ______, affiant exhibited to me his/her Residence Certificate No.
_________________ issued at __________ on ____________,20 __________.

Doc. No. ________

Page No. ________
Book No. ________
Series of ________

NOTARY PUBLIC