DECLARATION OF PENDENCY/NON-PENDENCY OF CASE

I, _____________________________________________, Filipino of legal age, with

permanent address at _______________________________________________________,
and holder of the position _________________________________________ at the
___________________________________________________, after being sworn in
accordance with law, hereby depose and state that:

1. I am applying for my _____________________________________ effective

__________________________________________:

2. I have:
2.1 no pending case1
2.2 a pending case

• administrative disciplinary case

• criminal case

3. The NATURE/SPECIFIC OFFENSE CHARGED in the pending

criminal/administrative disciplinary case is : _____________________________
_________________________________________________________________

4. The venue of the investigation/trial: ____________________________________

5. On appeal: YES NO

6. The appeal is pending before: _________________________________________

7. I am executing this Declaration of Pendency/Non-Pendency of Case to attest to

the truth of the foregoing facts and to enable me to process and secure the release
of my retirement benefits.

8. By executing this Declaration of Pendency / Non-Pendency of Case, I hereby

authorize the Head of Agency to verify the status of any case(s) filed against
me in any forum.

9. Further, I am executing this Declaration of Pendency / Non-Pendency of Case

under pain of criminal and/or administrative liability under existing laws.

________________________________
Signature over printed name

SUBSCRIBED AND SWORN to before me this ___ day of __________________,

affiant exhibiting to me his / her ________________________________.

____________________________
(Person Administering Oath)

1
A pending case shall refer to both criminal and administrative disciplinary case. An administrative disciplinary case is considered when
the disciplining authority has issued a formal charge or a notice of charge to the respondent, while a criminal case shall be considered
pending from the time an Information or Complaint is filed in court.