Republic of the Philippines)

Province of La Union) S.S

City of San Fernando)
x------------------x

AFFIDAVIT
(of Declaration of Source of Income)

I, MARK BAGSINGIT, Filipino, single, of legal age, and with residence address at
Lipay Proper San Gabriel, La Union, Philippines, after having been sworn to in accordance
with law, hereby depose and state: THAT –

1. Mark Bagsingit was he had no employer other than himself and derived income from
his physical and mental efforts as RICE FARMER from 03/1998 until 05/2007 at
Balidbid, Salcedo, Ilocos Sur.

2. Should SSS determine any misrepresentation as to my statements in this Affidavit or

should SSS find that I am not qualified to be registered as self-employed member, I
agree that my SSS membership registration as well as entitlement to all SSS benefits
shall be revoked and all my remitted contributions shall be refunded.

3. I have read and understood the contents herein and swear under the penalty or Perjury
pursuant to Article 183 of the Revised Penal Code; and Falsification pursuant to
Section 28 (a) of RA 1161, as amended (Social Security Law).

4. I am executing this affidavit to attest to the truth of the foregoing and for the purpose
of applying for late registration of SSS membership

IN WITNESS WHEREOF, I have hereunto set my hand this September 6, 2021 in

San Fernando City, La Union.

MARK BAGSINGIT
Affiant

SUBSCRIBED AND SWORN to before me this September 6, 2021in San Fernando

City, La Union.