REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ALBAY ) S.S.

TABACO CITY )
x------------------------------------------x

AFFIDAVIT FOR ANTI-GRAFT AND CORRUPT

PRACTICES (RA 3019)
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 currently/formerly employed as ________________________________ in the

Commission on Audit.

2. That I am retiring/ under RA 1616/PD 1146/RA 8291 to take effect/effective on

_______________________.

3. That there is no administrative or criminal investigation against me for any offense, defined

or penalized under RA 3019, otherwise known as the Anti-Graft and Corrupt Practices Act, as
amended, and under the provisions of the Revised Penal Code on Bribery; and

4. That I am executing this affidavit to attest to the truth of the foregoing facts or assertation
in compliance with COA Memorandum No. 451 dated March 6, 1973.

IN WITNESS WHEREOF, I have set my hand and affixed my signature this _________ day of
______________, 20 ______ at _______________________.

_______________________________

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _______ day of ___________, 20 ______,

affiant exhibited to me his Government Issued ID __________ No. ______________ issued at
__________________ on ___________________.

ATTY. ANTHONY CLARK A. GAPIDO

Notary Public Tabaco City
For the Province of Albay
Roll No. 83746
IBP OR No. 227570; June 13, 2022
PTR No. 8843533; July 13, 2022 at Tabaco City
MCLE: N/A (Newly Admitted to the Bar)
2nd Floor Coastal Building Rental, Purok 2,
Morales Street, San Roque,Tabaco City, 4511

Doc No.____;
Page No. 450;
Book No. 35 ;
Series of 2022