Republic of the Philippines)

Camiling, Tarlac
) S.S.

AFFIDAVIT
I, CARLOS B. CALUSCUSAN, 60 years old, married, Filipino citizen and a
resident of Barangay Poblacion Norte, Mayantoc, Tarlac, Philippines, after having
been duly sworn to in accordance with law, do hereby depose and state THAT:
1. I am a member of the Social Security System with identification number
07-0740062-8;
2. In the year 1976, I worked as a Laborer at the Manuel Teves Corp, located
at Rosario Bais City, Negros Oriental and on October 1980 I worked at the
Tarlac Fortune Rice Mill, Poblacion Norte, Mayantoc, Tarlac;
3. On February 2009 my contract with my last employer, Tarlac Fortune Rice
Mill ended. Since then on, I ceased doing my usual work. I did not find any
other employment or engaged in any gainful activity up to the present;
4. Recently, I went to the SSS Camiling, Tarlac to file my retirement benefit
claim and upon processing it was discovered in my SSS record that aside
from my last employer above-stated, there is another company listed
therein which is the LNC Marketing;
5. I am executing this Affidavit to request the concerned agency to delete the
LNC Marketing in my SSS record as my last employer;
6. Finally, I am executing this affidavit to attest to the truth of the foregoing
statements and to support my application for my Retirement from the
Social Security System and for all legal intents and purposes this may
serve.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 21 st day
of March, 2014 at Camiling, Tarlac, Philippines.
CARLOS B. CALUSCUSAN
Affiant
SUBSCRIBED AND SWORN to before me this 7th day of December, 2010 at
Camiling, Tarlac. Affiant exhibited to me his Social Security System Identification
Card with number 07-0740062-8 issued by the Social Security System.