Republic of the Philippines
______________
) S.S.
AFFIDAVIT FOR ANTI-GRAFT AND CORRUPT PRACTICES (RA 3019)/ PENDENCY/NONPENDENCY OF ADMINISTRATIVE/CRIMINAL CASE
(Survivorship)
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 the ____________________ of the late ____________________________
who was an employee of the Commission on Audit (COA) until his/her death on
_____________________________;
2. That I am applying for GSIS survivorship benefits as a surviving spouse/heir effective
_______________________;
3. That to the best of my knowledge, my husband/wife/mother/father has no
administrative or criminal investigation/charges against him/her 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;
4. Please check [√] appropriate box:
That there is no pending administrative or criminal case filed against
him/her in any forum;
That there is a pending case against him/her, details of which as follows:
Administrative case
Criminal case
Nature/specific offenses charged: ________________________________
(specify)
5. 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 and
for the expeditious processing of the survivorship benefits.
IN WITNESS HEREOF, 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 Residence Certificate No. ______________ issued at
__________________ on ____________________.
Doc. No. ________
Page No. ________
Book No. ________
Series of ________
NOTARY PUBLIC