Republic of the Philippines )

City of __________ ) S.S.

AFFIDAVIT OF UNDERTAKING

I/We,(Name of Claimant Wife/Husband/Siblings/Parents/Children/Nieces/Nephews), all

of legal age, married/single, Filipino, with residence at (Address of Residence),
(hereinafter referred as NOK) after having been sworn in accordance with law, hereby
depose and state that:

1. OFW (Name of OFW) (“Employee”), with Philippine Passport No. ____________

issued on _(Date of Issue) , died in _(Place of death)______ on (Date of Death).
Employee died without leaving any last will and testament, has no debts, and has
no other surviving legal heirs except for the following:

Name of Legal Heir Relationship to the Employee

(Indicate if Minor or Legal Age)

2. The employer of the Employee requested the Philippine Embassy in Riyadh to

transfer to the NOK the amount SAUDI RIYALS (SAR)__________________ as
death benefit/end-of-service benefits (ESB), with authority given to the
Department of Foreign Affairs to identify the NOK on the basis of appropriate
SAMPLE ONLY documents.
Philippine government

3. (For minors) I, (name of mother), the mother and legal guardian of minor
child(ren) of the employee above listed. I am authorized to receive the share of
my minor child(ren) from the death benefits/ESB.

4. The NOK requests and authorizes the Office of the Undersecretary for Migrant
Workers Affairs (OUMWA) to release the Philippine peso equivalent of the death
benefit/ESB minus bank and other remittance charges as follows: (Please check
chosen box)

a. [ ]For claiming in person by NOK

b. [ ]Bank-to-bank transfer to (Name of Bank, Branch Account Number)
under the name of (Name of bank account holder who must be one of the
NOK).
 5. The NOK shall immediately distribute to all beneficiaries of the Employee whose
filiation is supported by Philippine government documents. If another beneficiary
who was not earlier identified and did not receive a share in the death
benefits/ESB surfaces, the NOK shall return to OUMWA the amount meant for
the new beneficiary within 10 days from notice.

6. The NOK affirms that they have no claim against the Department of Foreign
Affairs or any of its officers or employees. In the event that another beneficiary
surfaces, the NOK shall keep free from harm and claim the Department of
Foreign Affairs and defend the latter against any proceedings that the new
beneficiary may institute.
SAMPLE ONLY
7. This Affidavit of Undertaking is executed to attest to the truth of the foregoing and
binds the NOK with the undertakings aforementioned. The NOK shall be liable for
perjury, estafa, and other related felonies or crimes for any falsehood in this
Affidavit or for non-performance of the undertakings stated therein which we
assume with full understanding of its consequences.

______________________ ____________________
(Name of Affiant 1) (Name of Affiant 2)
(Government Issued ID) (Government Issued ID)

______________________ ____________________
(Name of Affiant 3) (Name of Affiant 4)
(Government Issued ID) (Government Issued ID)

SUBSCRIBED AND SWORN to before me this ___ day of _______, affiants

exhibiting to me their identification documents indicated below their respective names.

_____________________
(Subscribing Officer)

Document No. ________

Page No. ____________
Book No. ____________
Series of 20__________