Republic of the Philippines )

Province of Leyte ) s.c.

City of Tacloban )

AFFIDAVIT OF NON-PENDENCY OF
ADMINISTRATIVE/ CRIMINAL CASE

I, XXX, of legal age, Filipino, with permanent address at Palo, Leyte, after having
been duly sworn to in accordance with law, hereby voluntarily depose and say:

1. I am an employee with a position of Administrative Office I of the

Municipality of Palo, Province of Leyte;

2. That I am applying for authority to travel abroad on April 8 to April 30,

2017;

3. That there is no pending administrative criminal investigation against

me for any offense, defined or penalized under RA 3019, otherwise known as
the Anti-Graft and Corrupt Practices Act, as amended and under the provisions
of the Revised Penal Code;

4. That I am executing this affidavit to attest to the truth of the foregoing

facts for the expeditious processing of my retirement benefits.

IN WITNESS HEREOF, I have set my hand and affixed my signature this __

day of March 2017 atTacloban City, Leyte, Philippines.

XXX
(Affiant)

SUBSCRIBED AND SWORN TO BEFORE ME this _______ day of March

2017 at Tacloban City, Leyte, Philippines, affiant exhibited to me her Government Issued
ID __________with No._________________ issued at ____________________ on
____________________.