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Republic of the Philippines)

Province of _______________) s.s.



I, JUANA DELA CRUZ, of legal age, married, Filipino citizen and a

resident of ___________________, Philippines, after having been sworn to on
oath in accordance to law, hereby depose and state that:

1. I am an overseas Filipino worker in Hongkong. I am employed for a

two-year contract from December 02, 2012 until December 2014, as
a domestic helper to my employer Chan, Yun Tse;

2. However, on 23 April 2013, I went home to the Philippines and did

not finish my contract. I suffered verbal abused from my employer,
she was so strict when it comes to cleanliness as she always orders
me to repeat cleaning and as a result, I am sleeping very late at
night. During meals, she only gave me little food and sometimes I
don’t have a breakfast;

3. I therefore execute this affidavit to attest to the truth of the

foregoing facts and circumstance and for all legal intents and
purposes that it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

______________ in ___________________________, Philippines.


ID No.

SUBSCRIBED AND SWORN TO BEFORE ME this ____________________ in

_________________________, Philippines, by the affiant who is known to me on the basis
of competent document shown as proof of her identity.