SSS Form E-417

REPUBLIC OF THE PHILIPPINES )

City/Municipality of ____________ )
___________________________ ) S.S.
Province of __________________ )

AFFIDAVIT OF SEPARATION FROM EMPLOYMENT

I, _________________________ of legal age _________________ Filipino and

residing at ______________________________________ after having been sworn
to in accordance with law hereby depose and state:
1. That I am a bonafide member of the Social Security
System with SSS number _______________________

2. That I was separated from my last employer, _____________

____________________, with address at ________________
____________________ on _______________ thereafter,
I was never again re-employed.

3. That I cannot secure a certification of separation

from my last employer because ________________________

4. T h a t I a m e x e c u t i n g t h i s a ff i d a v i t t o a t t e s t t o t h e
truth of the foregoing facts and to support my
________________________________________________.
FURTHER AFFIANT SAYETH NAUGHT.

Affiant
SUBSCRIBED AND SWORN TO BEFORE ME this _____________ day of
_____ 20___ in Quezon City, Philippines, affiant having
exhibited to me his/her Residence Certificate No. ___________________
_______________ issued in _________________________ on ________
20_________.

Notary Public
Until December 31, 20 ___
PTR No. _____________
Issued at _____________
DOC NO. ____________ Issued on _____________
PAGE NO. ____________
BOOK NO. ____________
SERIES OF ____________