Affidavit For Anti-Graft And Corrupt

Practices (Survivorship)
Republic of the Philippines )
___________________________ ) SS.
x- - - - - - - - - - - - - - - - - - - - - x

AFFIDAVIT FOR ANTI-GRAFT AND CORRUPT PRACTICES (RA

3019)
(Survivorship)

I, _______________________________, of legal age, Filipino, widow/widower and

presently residing at ___________________________ having been duly sworn to in accordance
with law, depose and say:

1. That I am the widow/widower of _______________________________________

who was an employee of the Commission on Audit (COA) until his/her death
on ______________________.

2. That I have applied for GSIS survivorship benefits as a surviving spouse

effective _____________________.

3. That to the best of my knowledge, my husband/wife has no

administrative/criminal investigation/charges against him/her for any offense, defined or
penalized under RA 2019, otherwise known as the Anti-Graft and Corrupt Practices Act, as
amended, and under the provisions of the Revised Penal Code on Bribery; 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 WHEREOF, I have set my hand and affixed my signature this _________
day of ______________, 20 ______ at _______________________.

____________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _______ day of ___________, 20

______, affiant exhibited to me his Government Issued ID __________ No. ______________
issued at __________________ on ___________________.
Doc. No. _____
Page No. _____
Book No. _____
Series of _____