Republic of the Philippines

Province of Samar
Municipality of ____________

AFFIDAVIT OF UNDERTAKING
I, DAMIANA DOCULAN-CABOTE, of legal age, widow, Filipino and resident of
Brgy. Batiawan, Taft, Eastern Samar, after having been duly sworn to in accordance
with law, hereby depose and say, THAT:

a. I am the surviving spouse of MARIO R. CABOTE who died on June

13, 2019 at Cebu City;

b. My deceased husband Mario Cabote had maintain an Account

with Armed Forces & Police Savings & Loan Association, Inc.
(AFPSLAI) Catbalogan Branch with Account No.
_______________;

c. The said account is the sole account/money left by my

deceased husband;

d. I am the legal surviving spouse of the deceased we having been

married on ______________ at_______________. (hereto attached is
Photocopy of Marriage Certificate);

e. It is now my intention to apply and claim the Assistance to Lift

Members’ Survivors (ALMS) with AFPSLAI-Catbalogan Branch;

f. In view of the foregoing, I hereby UNDERTAKE to indemnify the

Association (AFPSLAI) for whatever damages and will keep the
Association free and harmless from any liability for any claims
that may be made later on by any third persons;

g. Further, I hereby RELEASE the Association, its officers and/or

employees, from any claims and controversy from any third
person or entity involving the above-mentioned claims.

IN WITNESS WHEREOF, I hereunto affix my signature this________________ at

___________________.

DAMIANA DOCULAN-CABOTE
Affiant
ID No. ____________________

SUBSCRIBED and SWORN TO BEFORE ME this ___________________at the

_________________, Philippines, affiant exhibited her identification card shown above.

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Book No.
Series of 2019