Republic of the Philippines )

DONE: ____________ ) S. S.
x--------------------------------x

AFFIDAVIT OF AUTHORIZATION
AND UNDERTAKING

I, ______________, of legal age, Filipino citizen, single, and a resident of

_____________________, Philippines after having been duly sworn in accordance
with law, hereby state and declare:
1. That I was employed with the ____________________________ with
office address at ____________________. I was employed with the
______________ from ___________ to _____________.

2. That by reason of the cessation of my employment with the

______________, I applied for the monetization of my Terminal Leave
Benefits;

3. That by reason of my application for monetization of my Terminal Leave

Benefits. I am hereby authorizing the ___________ to deduct all of my
financial obligations, if any from the Monetization of my Terminal Leave
Benefits;

4. That I also attest and undertake that there is no pending criminal

investigation against me under RA 3019;

5. I attest to the truth of the foregoing in order to monetize of my Terminal

Leave Benefits. I execute this Affidavit for all legal intents and purposes
that this may serve.

WHEREFORE, I have hereunto set my hand this ___ day of

____________2019, in Baguio City, Philippines.

_________________
Affiant
ID: __________

SUBSCRIBED AND SWORN TO BEFORE ME this ____ day of

___________ 2019 in Baguio City, Philippines.

Doc. No.
Page No.
Book No. Notary Public
Series of 2019.