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Republic of the Philippines )

______________________ ) S. S.

AFFIDAVIT
I, _____________________________________________________________
of
legal
age,
__________________________
presently
residing
at
_____________________________________________________________________
having been duly sworn to in accordance with law, depose and say:
1. That
I
was
formerly
employed
as
_______________________________________________________ in the
__________________________________________________________;
2. That I am retiring under RA1616/PD 1146, RA660 effective
____________________________________________________________;
3. That there is no administrative criminal investigation against me for any
offense, defined or penalized under RA3019, otherwise known as the AntiGraft and Corrupt Practices Act, as amended and under the provisions of
the Revised Penal Code; 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 _____________________, ___________________ at
________________________________.
_________________________
Affiant
SUBSCRIBED AND SWORN TO BEFORE ME this ________ day of
____________________, ___________ in _____________________________,
affiant exhibiting to me his/her Residence Certificate No. ______________________.
Doc. No. __________
Page No. __________
Book No. __________
Series of __________

__________________________
Notary Public

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