Republic of the Philippines)

Quezon City……..………………) S.S.

AFFIDAVIT OF SEPARATION

I, ANTONIO Q. SIMANGAN III, Filipino, of legal age, married and a resident of Barangay Malaya,
Quezon City, after being duly sworn, hereby depose and state under oath, that:

1. I am the General Manager of New City Food House Inc., a company engaged in the business of
serving affordable Chinese and Filipino food with principal office at, 16 Kalayaan Ave., Diliman, Q.C.
As GM, I take overall charge of the operations of the company and exercise direct control and
supervision over its affairs.

2. Our company had under its employ the following persons who have been enrolled with the
government’s Social Security System and assigned the corresponding social security numbers, to wit:

Name SSS Number Date Separated

Angelita B. Dizon 3391232089 December, 2016
Erwin N. Indino 3400994687 June 1, 2017

3. On the following given dates, the above-listed persons were separated from their employment with
our company, and thereafter, were never again re-employed, viz.

4. As a result of the foregoing, now ceases to be their employer.

5. In behalf of the company, I am executing this Affidavit to attest to the truthfulness of the fact
6. of their severance from our employment and to put on record this truism.

Further Affiant sayeth none.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 21 day of February, 2018 in
Quezon City, Philippines.

........................................................................
ANTONIO Q. SIMANGAN III

SUBSCRIBED AND SWORN before me this........ day of ........................... 20__, by

............................................. who exhibited to me his CTC No. ................................... issued on
................................. at ...........................................

Notary Public

Doc. No. .........:

Page No. .........;
Book No. .........;
Series of 20__.