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REPUBLIC OF THE PHILIPPINES)

PASIG CITY ) S.S.

AFFIDAVIT OF CLAIM

I, ________________, Filipino, single, of legal age and currently residing at


____ M. H. Del Pilar Street, Guitnang Bayan 1, San Mateo, Rizal, after having
duly sworn in accordance with law hereby depose and state that:

1. I am presently employed by _________________, Inc. (the “Company”).

2. My permanent residence located at _____ M. H. Del Pilar Street, Guitnang


Bayan 1, San Mateo, Rizal, was totally destructed by fire which occurred
last __________________.

3. As proof of my identity, residency and destruction/damage to my


residence, I attached hereto three (3) copies of my photos and faithful
reproductions of my LTO-issued license with No. _______________, the
same was used in notarization of this instrument, Certificate of Residency
issued by the Barangay Office having the jurisdiction over my residence,
and Certificate of Fire Incident issued by the Bureau of Fire Protection who
conducted investigation after fire occurrence.

4. The residence destructed by fire was the same residence I declared before
the Human Resources Department as my permanent residence. The same
also appears as my permanent residence in my employee file.

5. I understand that I am entitled to the Calamity Assistance from the


Company, on account of the above-mentioned fortuitous event, only once.

6. I declare that I have not filed any Calamity Assistance before the
Company on account of the same incident.

7. I acknowledge the Company, its agents, employees or its duly authorized


representatives’ right to verify the veracity of my claim, to make inquiries
and background checks, or to conduct any investigation to confirm any
information relating to the circumstances of my claim.

8. I further acknowledge that any misrepresentation in this claim or


submission of any fake document may lead to disciplinary action,
including termination of my employment.

9. I am executing this affidavit to attest to the truth of the foregoing and to


support my claim for Calamity Assistance.

IN WITNESS WHEREOF, I have hereunto set my hand in Pasig City, this


11 April 2019.

___________________________
Affiant
SUBSCRIBED AND SWORN TO before me this 11 April 2019 in Pasig
City, affiant exhibiting to me her Driver’s License with No. NO1-11-010726, with
expiry date on 2022/12/06.

Doc. No. _____;


Page No. _____;
Book No. _____;
Series of 2019.