ANNEX “A”

AFFIDAVIT OF UNDERTAKING
I, __________________________, Filipino, of legal age, married/single with residence
address at ____________________________________________________, after having
been subscribed to an oath profess, undertake, and agree to the following:
1. I and/or any member of my family, as enumerated in the Social Amelioration Program
form, have not received any assistance related to the Emergency Subsidy Program –
Social Amelioration Program of any of the following organizations:
a. Department of Social Welfare and Development (DSWD);
b. Department of Labor and Employment (DOLE);
c. Department of Agriculture (DA);
d. Social Security System (SSS); and/or
e. Land Transportation Franchising and Regulatory Board (LTFRB).
2. I am allowing the Department of Social Welfare and Development to share my
personal information, particularly my (1) name and (2) address [province and
municipality], to other Government Agencies for the purposes of transparency and/or
research:
3. I am signing on my own free will.
If found to be a beneficiary of any of the abovementioned organizations, I will return the grant I
received in full and without question to the DSWD Field Office 02. Failure to return the grant
within 7 days from notice that I am a duplicate beneficiary shall subject me to investigation by
the Criminal Investigation and Detection Group (CIDG) for possible civil, administrative (if
applicable), and criminal liability.
I also attest that the abovementioned provisions were fully explained to me and that I have
understood the entire document.
In witness hereof, I hereby set my hand this ____ the day of April, 2021, in
_____________________________.
____________________________________
(Signature over printed name of beneficiary)
Witness:
Beneficiary ANNEX “A”
AFFIDAVIT OF UNDERTAKING
’s Copy
I, __________________________, Filipino, of legal age, married/single with residence
address at ____________________________________________________, after having
been subscribed to an oath profess, undertake, and agree to the following:
1. I and/or any member of my family, as enumerated in the Social Amelioration Program
form, have not received any assistance related to the Emergency Subsidy Program –
Social Amelioration Program of any of the following organizations:
a. Department of Social Welfare and Development (DSWD);
b. Department of Labor and Employment (DOLE);
c. Department of Agriculture (DA);
d. Social Security System (SSS); and/or
e. Land Transportation Franchising and Regulatory Board (LTFRB).
2. I am allowing the Department of Social Welfare and Development to share my
personal information, particularly my (1) name and (2) address [province and
municipality], to other Government Agencies for the purposes of transparency and/or
research:
3. I am signing on my own free will.
If found to be a beneficiary of any of the abovementioned organizations, I will return the grant I
received in full and without question to the DSWD Field Office 02. Failure to return the grant
within 7 days from notice that I am a duplicate beneficiary shall subject me to investigation by
the Criminal Investigation and Detection Group (CIDG) for possible civil, administrative (if
applicable), and criminal liability.
I also attest that the abovementioned provisions were fully explained to me and that I have
understood the entire document.
In witness hereof, I hereby set my hand this ____ the day of April, 2021, in
_____________________________.
____________________________________
(Signature over printed name of beneficiary)

Witness:
___________________________________
(Signature over printed name of Barangay
Captain or LGU Representative) ___________________________________
(Signature over printed name of Barangay
Captain or LGU Representative)