Republic of the Philippines
______________
) S.S.
AFFIDAVIT FOR ANTI-GRAFT AND CORRUPT PRACTICES (RA 3019)/ PENDENCY/NONPENDENCY OF ADMINISTRATIVE/CRIMINAL CASE
(Retirement/Resignation)
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 currently/formerly employed as ________________________________
in the Commission on Audit;
2. That I am applying for retirement/resignation to take effect/effective on
_______________________;
3. That there is no administrative or 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 on
Bribery;
4. Please 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 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 my retirement/separation 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 Government Issued ID __________No.______________
issued at __________________ on ____________________.
Doc. No. ________
Page No. ________
Book No. ________
Series of ________
NOTARY PUBLIC