ANNEX “ ____”

REPUBLIC OF THE PHILIPPINES

____________________________
____________________________

AFFIDAVIT OF UNDERTAKING

I, ________________________________ of legal age, married/single and

a resident of _____________________________________________________
after having been duly sworn on oath in accordance with law, do hereby depose
and say:

1) That I am an employee of the ______________________________

having been appointed/designated as Clerk of Court/Officer-in-Charge;

2) That I am in-charge in the handling of court collections and remittances

thereof;

3) That I am securing a Supreme Court Clearance for travel abroad

purposes/study leave application;

4) That I promise to comply with the requirements of the Fiscal Monitoring

Division, CMO regarding the Audit of my financial transactions as
accountable officer immediately after my return;

5) That in case of failure to comply with the requirements, I am giving

authority to the Chief of the Financial Management Office to withhold my
salaries and other allowances effective ________________.

IN TRUTH WHEREOF, I have hereunto sign my name below this ______

day of ________________ at ________________.

________________
Affiant

SUBSCRIBED AND SWORN TO before me this ____________ day of

________________ 20____ affiant exhibiting to me his/her CTC #
____________________ issued at ________________ on _________________.