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Affidavit for Anti-Graft and Corrupt Practices - Survivorship

COA affidavit for anti-graft and corruption practices for survivorship

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______________
) S.S.

AFFIDAVIT FOR ANTI-GRAFT AND CORRUPT PRACTICES ACT (RA 3019)
(Survivorship)

I, ________________, of legal age, Filipino, widow/widower, and presently residing at
_____________________________________________________________________________,
having been duly sworn to in accordance with law, depose and say:
1. That I am the widow/widower of _______________________________________ who
was an employee of the
Commission on Audit (COA) until his/her death on
______________________.
2. That I have applied for GSIS survivorship benefits as a surviving spouse effective
_____________________.
3. That to the best of my knowledge, my husband/wife has no administrative/criminal
investigation/charges against him/her for any offense, defined or penalized under RA
2019, otherwise known as the Anti-Graft and Corrupt Practices Act, as amended, and and
under the provisions of the Revised Penal Code on Bribery; 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 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/her Government issued ID
____________No._________________ issued at __________ on ____________.
Doc. No. ________
Page No. ________
Book No. ________
Series of ________

NOTARY PUBLIC
 
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