REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ALBAY ) S.S.

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

AFFIDAVIT OF PENDENCY/NON-PENDENCY OF
ADMINISTRATIVE/CRIMINAL CASE
(Survivorship)

I, _______________________________, of legal age, Filipino, widow/widower and with

permanent address at ___________________________ after having been duly sworn
to in accordance with law, hereby voluntarily depose and say:
1. That my husband/wife was employed as
_______________________________at the Commission on Audit prior to his/her
death on __________________________;
2. That I am applying for Survivorship benefits effective
_______________________;

3. Pls. check [√] appropriate box

________ That there is no pending administrative or criminal case filed against me in

any forum

________ That there is a pending case against me, details of which are as follows:

________ Administrative ________ Criminal

Nature/specific offenses charged: _______________________________

4. That I am executing this affidavit to attest to the truth of the foregoing facts.

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