REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ALBAY ) S.S.

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

AFFIDAVIT

I, _________________, of legal age, single/married/widow, Filipino citizen, and

presently residing at _____________________, after having been duly sworn to in
accordance with law, do hereby depose and say:
1. That I was formerly employed as ____________________________ in the
________________________________________;
2. That I am retiring under RA1616/PD 1146, RA660 effective
__________________.
3. That there is no administrative 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; 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 hereunto set my hand this ____ day of ___________
20____ in ____________, _____________, Philippines.

___________________________________

Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of _________ at

________________ affiant exhibited to his/her competent evidence of identity by way of
_________________ issued on __________________ in _______________,
Philippines.

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