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Republic of the Philippines

______________
) S.S.
AFFIDAVIT OF PENDENCY/NON-PENDENCY OF ADMINISTRATIVE/ CRIMINAL
CASE
I, __________________________________, of legal age, Filipino, with permanent
address at _________________________________________________, after having been duly
sworn to in accordance with law, hereby voluntarily depose and say:
1.

I
am
currently/formerly
employed
________________________________ in the Commission on Audit;

2.

That I am applying for optional/compulsory retirement to take effect/effective


on _______________________;

3.

as

Pls. 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 are as follows:
Administrative case

Criminal case

Nature/specific offenses charged: _________________________________


(specify)
4.

That I am executing this affidavit to attest to the truth of the foregoing facts
for the expeditious processing of my retirement 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/her Government Issued ID
__________with No._________________
issued at ____________________ on
____________________.
Doc. No. ________
Page No. ________
Book No. ________
Series of ________

NOTARY PUBLIC