UNDERTAKING

I, ____________________________, hereby confirm that I have received payment of my full Maternity Benefit provided for by
applicable law and the rules from [employer name] (“Company”) on ___________________.

In view of my receipt of my full Maternity Benefit, I hereby undertake that I will submit all the required documents to process the
Company’s claim from the Social Security System as likewise provided for by law and the rules:

SSS Maternity Notification (MAT1) Requirements:

 SSS Maternity Notification form (version SIC-01241 12-2015)
 SSS Maternity Reimbursement form (version SIC-01242 12-2015)
 CompleteOB History (accomplished by OB Gyne, and states the number of pregnancies w/ exact date of delivery/miscarriage)
 Original Ultrasound Report with expected date of delivery
 Maternity Benefit Undertaking form (MBUF)
 Updated SSS Contribution print out
 Photocopy of 2 valid IDs
 Three (3) specimen signatures
 SSS Allocation of Maternity Leave Credits (version SMD-01409 05-2019)

SSS Maternity Reimbursement (MAT2) Requirements:

 SSS Maternity Reimbursement form (version SIC-01242 12-2015)
 CompleteOB History (accomplished by OB Gyne, and states the number of pregnancies w/ exact date of delivery/miscarriage)
 Certified True Copy of child’s birth certificate
 Certified True Copy of Operating Room Records **for CS delivery only
 Certified True Copy of Discharge Summary **for CS delivery only
 CertifiedTrueCopy of Death Certificate or fetal death certificate **if child dies or is a stillborn
 Fact of birth **for lying-in patients
 Updated SSS Contribution print out
 Photocopy of 2 valid IDs
 Three (3) specimen signatures
 Pay Slip which shows the payout of the Full Pay Benefit

Additional Documents for those with change of Name due to Marriage/Annulment

Employee’s Birth Certificate (Certified True Copy)
Marriage certificate, if married
Death Certificate of spouse, if due to death of previously reported spouse
Certificate of Finality of Annulment/Nullity or annotated Marriage Contract/Certificate, if due to annulled or void marriage
with previously reported spouse
Court Order on Declaration of Presumptive Death, if previously reported spouse is presumed dead
Decree of Divorce and Certificate of Naturalization (granted before divorce) or its equivalent, if due to divorce with
previously reported spouse
Certificate of Divorce (OCRG Form No. 102), if due to divorce of Muslim member with previously reported spouse

I likewise undertake and consent to allow the Company to put my salary on hold on the second payout upon return to work if I fail
comply with either of the following:

a) Failure to submit all the applicable documents as indicated above 45 days after my Expected Date of Delivery or;
b) Failure to confirm/certify receipt of the SSS maternity benefit on the second attempt of the Company to process
Maternity Benefit Reimbursement Application online. Confirmation/certification should happen within 7 days upon
receipt of email from SSS.

I also undertake and consent to allow the Company to deduct the said Maternity Benefit including the salary differential (if any)
from my salary/final pay due to the following reasons:
a) Social contributions for SSS, HDMF and Philhealth (including penalties and late charges in the event that the SSS benefit
was availed after my maternity leave) advanced by the Company for the period of my Maternity
b) Overpayment of the Maternity Benefit (eg: SSS Reimbursement is lower than amount credited to me by the Company)
c) SSS declines the reimbursement claim of the Company for reasons attributable to Employee.

Finally, in case of separation from the Company and my SSS Benefit is not yet reimbursed, I understand that the amount credited to
me by the Company will be deducted from my Final Pay and a second check will be created once the amount is reimbursed by SSS.
Hence, I will monitor my SSS Maternity Claim via the SSS Website or Mobile App and shall provide a screenshot of the proof of
reimbursement to HR to process the second check.

I have read and understood the contents of this Undertaking and confirm that I fully and freely consent to all that I have undertaken.

______________________________________
[Signature over printer name of the employee]
[date signed]