Republic of the Philippines)

Province of____________ )S. S.

AFFIDAVIT OF AUTHENTICITY/UNDERTAKING

I, _______________________________________,of legal age, Filipino and a

resident of __________________________________________________________, after
having been sworn to in accordance with law, depose and say:

That, I am the legitimate claimant (wife/husband/sibling/beneficiary) of the late

______________________________________;

That, I have submitted the pertinent documents before the PNP Retirement and
Benefits Service, Camp Crame, Quezon City in support to my claim retirement benefits;

That the contents of the above-stated documents are genuine and authentic and the
original thereof are now in my possession readily available for verification and comparison
purposes;

That I hold myself liable for perjury, falsehood, misrepresentation or omission or any
act of dishonesty for any fraudulent, fake or tampered documents that I have submitted;

That I agree to automatic stoppage of my claims for retirement benefits if any of those
above-stated documents are found fake or fraudulent;

That I attest to the truthfulness of this undertaking and I submit to the legal and
administrative consequences thereof if the statements above are wanting in truth and
substance.

IN WITNESS HEREOF, I hereto unto affix my hand and signature this day of
________________________, in ______________________________, Philippines.

________________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this day of

_________________________ , at ____________________________, Philippines, affiant
exhibiting identification card ________________________ as a competent evidence of
his/her identity.

Doc No. _________

Page No._________
Book No. _________ Notary
Series No. ________