AFFIDAVIT

(of Declaration of Source of Income)I ________________________________ !ith Social Security "o.

________________

(Complete Name of Affiant)

#ilipino __________________ of le$al a$e an% !ith resi%ence a%%%ress at _______________

(Civil Status)

___________________________________ after havin$ been s!orn to in accor%ance !ith la!

(Complete Residence Address of Affiant)

hereby %epose an% state& ' ' *+. I am

self-employed

as I have no employer other than myself an% %erive income from myphysical an% mental efforts as&
_______________________ from _________ until _________ at _______________________.

(Nature of Self-Employment) (Start) (End) (Where Conducted)

2.

Shoul% SSS %etermine

any mispresentation

as to my statements in this ffi%avit or shoul%SSS fin% that I am

not qualified

to be re$istere% as self,employe% member I a$ree that mySSS membership re$istration as !ell as

entitlement to all SSS benefits shall be

revoked

an% allmy remitte% contributions shall be

refunded.
-. I have rea% an% un%erstoo% the contents herein an% s!ear un%er the penalty or

Perjury

pursuant to rticle + - of the Revise% Penal Co%e an%

Falsification

pursuant to Section 0 (a)of R ++1+ as amen%e% (Social Security 2a!).3. I am e4ecutin$ this
ffi%avit to attest to the truth of the fore$oin$ an% for the purpose of applyin$ for late re$istration as a
Self,5mploye% SSS Member.

IN ITN!"" #!$!%F

I have hereunto set my han% this _________________%ay of _______________ 06+7 in

____________________________ Philippines. ___________________________________

Affiant

"&'"($I'!D AND " %$N T% '!F%$! )!

this ____ %ay of _________ ffiante4hibitin$ to me his/her Community 'a4 Certificate "o.
______________ issue% on ________ at ___________________

and

__________ ID "o. ______________ issue% on ____________ in _________________.

N%TA$* P&'+I(

Doc. "o. _____ Pa$e "o. ____ 8oo9 "o. ____ Series of ____.