Republic of the Philippines )

) S.S.
x----------------------x

AFFIDAVIT OF UNDERTAKING

I, (name), of legal age, (citizenship), (civil status), and with permanent address at
(address), after having been duly sworn to in accordance with law, hereby depose and
state that:

1. I am the Legal Beneficiary or Claimant of ___________________, a Principal

Member of Pag-IBIG Fund for the total saving and additional death benefits.

2. At present, I am now claiming the Provident Benefits proceeds due to

_____________.

3. I have understood the consequences as explained to me by the Officer and Staff

of the Pag-IBIG Fund as to the release of the Provident Benefits check in my
favor.

4. I hold Pag-IBIG Fund free from any liability, civil or criminal or of whatever
nature, that will arise from any third party claim in relation to the release of the
Provident check in my favor.

5. I hold myself solely responsible for any liability that will arise in connection with
the release of the Provident Benefits check of Pag-IBIG Fund in my favor.

6. I am executing this affidavit to attest to the truth of the foregoing facts and for
whatever legal purposes or intent this may duly serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of

_____________________, 2019 at Iloilo.

NAME
Affiant

SUBSCRIBED AND SWORN TO before me this ___ day of

____________________, 2019, affiant exhibited to me his/her ________________________
as his/her competent evidence of identity, issued at _______________________ on
_________________________________.