REPUBLIC OF THE PHILIPPINES

Province of Guimaras ) S.S.

AFFIDAVIT OF SEPARATION FROM EMPLOYMENT/

CESSATION OF SELF-EMPLOYMENT
WITH UNDERTAKING

I, _________________________, a Filipino, of legal age, married, with residence/

postal address at Barangay ____________________________, Philippines, after having been
sworn to in accordance with the law hereby depose and state that;

1. I am a bona fide member of the Social Security System (SSS) with assigned SS
Number/ Common Reference Number_____________________;

2. I cannot secure a certification and/or proofs from my last employment/self-

employment because I was never been employed;

3. I am aware of the nature, consequences and incurring liabilities

(criminal/civil/administrative) for any falsity, deceit, fraud, misrepresentation or
non-disclosure made in connection with my claim/ application for retirement
benefits under the SS Law and other applicable laws, rules, and regulations;

4. I hereby undertake to inform/notify the SSS on the fact of my re-employment/re

engagement in self-employment after availing of retirement benefits; and

5. I am executing this affidavit to attest to the truth and veracity of the foregoing
statements and to support my claim/application for retirement benefits.

Affiant further sayeth naught

IN WITNESS WHEREOF, I have set my hand and affix my signature this 3rd day of
January, 2020 at the Province of Guimaras, Philippines.

_________________________
ID: ______________

SUBSCRIBED AND SWORN to before me, a Notary Public for the Province of
Guimaras this ___________day of ______________, 2020 at _______________________,
Philippines. Affiants exhibiting to me his/her Community Tax certificate No.
________________ issued on ___________________ at __________________ and/or
Identification card No. __________ as proof of her identity.

Doc. No. _____;

Page No._____;
Book No. ____ ;
Series of 2020.