REPUBLIC OF THE PHILIPPINES)

City of Santiago) S.S.

AFFIDAVIT OF UNDERTAKING
(Sickness Benefit Claim)

I, MAGDALENA M DELA CRUZ, of legal age, Filipino citizen, married, with

address at # 005 carreon St., Centro East, Santiago City after having been duly sworn
in accordance with law, hereby depose and state that:

1. That I am currently an active voluntary member of the Social Security

System (SSS) with SS Number 0120158007;

2. That I was diagnosed as a positive confirmed case of COVID 19 last

January 13, 2022 by Dr. Eunice Stefanelle A Sibuyan and was advised to
undergo home isolation for 10 days while taking medications prescribed ;

3. That my income was seriously affected during the time I have undergone
the required isolation period making myself financially challenged at the
present ;

4. That I am executing this affidavit for the purpose of claiming sickness

benefits as a bonafide member of the Social Security System (SSS) which
may aid me to recuperate from my current financial situation have
hereunto attach all the supporting documents necessary to substantiate
my claim; ;

5. That I am aware that I may be criminally liable for any false statement or
representation made in this document or for any other documents
submitted in connection with my claim; and

6. That I am executing this affidavit to attest truthfulness, veracity and due

execution of the foregoing statements and documents.

IN WITNESS WHEREOF, I have hereunto set my hands this 23rd day of

February 2022 at Santiago City, Philippines.

MAGDALENA M DELA CRUZ

Affiant
CTC # 07116527

SUBSCRIBED AND SWORN to before me this 12th day of February, 2022 at

Santiago City, Philippines, affiant exhibiting her Community Tax Certificate issued on
January 27, 2022 at Santiago City, Isabela.

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