Republic of the Philippines )

Province of South Cotabato )S.S.

CITY OF KORONADAL )
x------------------------------------------x

AFFIDAVIT OF SEPARATION FROM EMPLOYMENT

I, _____________________, of legal age, Filipino, single, and a resident of

___________________, having been duly sworn according to law, hereby deposes
and states that:

1. I am a bona fide member of the Social Security System (SSS) with

assigned SS number/Common Reference Number _____________;

2. I was separated from my last employer on ______________ under

Magsaysay Maritime Corporation with main office address at Metro
Manila as seafarer in Saga Sapphire Ship, thereafter, I was never again
re-employed;

3. I involuntary separated from my employment on the fifth month of my

service and wasn’t able to finish my nine (9) months contract due to
economic downturn caused by Covid 19;

4. 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 benefits under the SS Law and other applicable
laws, rules and regulations;

5. I am executing this affidavit to attest to the truth and veracity of the

foregoing statements and to support my claim/application for benefits
and for whatever legal purpose this may serve.

IN TRUTH WHEREOF, I hereby affix my hand this _____________________,

in the City of Koronadal, South Cotabato, Philippines.

_____________________
Affiant
Philippines Passport no.
____________________

SUBSCRIBED AND SWORN TO before me this ___________________, in the

City of Koronadal, South Cotabato, affiant having exhibited to me his
Identification Card written below his name with his photograph appearing
thereon sufficient to prove his identity.

Doc. No.
Page No.
Book No.
Series of 2020.