REPUBLIC OF THE PHILIPPINES)

_________________________ ) S.S.

AFFIDAVIT OF UNDERTAKING
(With Survivorship Agreement)

I, ____________________________, widow/ widower/ single/ married,

Filipino, of legal age and with residence and postal address at
______________________________________________________, after having
been duly sworn to in accordance with law hereby depose and state:

1. That I am the husband/wife/daughter/son/mother/father

of the late ____________________________________ who died on
___________________;

2. That my wife/husband/mother/father/daughter/son was a bonafide

member of the Armed Forces and Police Savings and Loan Association, Inc.
(AFPSLAI);

3. That my wife/husband/mother/father/daughter/son and I hold a

CCA/Savings Account with AFPSLAI under a Survivorship Agreement;

4. That I am requesting AFPSLAI authorities to allow me to receive the

proceeds of the termination of the deceased’s account pursuant to our
Survivorship Agreement;

5. I undertake any and all responsibility and liability for non-entitlement in

connection with, arising out of, in any way relating to my transactions with
AFPSLAI for the processing, release and my receipt of the proceeds or
benefit;

6. I hold AFPSLAI free from any and all liabilities in relation thereto.

7. I am executing this undertaking under pain of perjury and penalty for

falsification for any untruthful statement sworn hereto.

IN WITNESS WHEREOF, I have hereunto set my hand this __________ day

of __________20___ at ________________.

__________________________
Affiant

REPUBLIC OF THE PHILIPPINES)

_________________________ ) S.S.

SUBSCRIBED AND SWORN to before me this ____ day of ______________

personally appeared ____________________________, with his/her
competent evidence of identity with __________________________ with ID No.
______________________.

Doc No. ____

Page No. ____
Book No. ____
Series of 20___.