SSS WAIVER

I, ________________________________________, of legal age, single/married, and a resident of

__________________________________________, do hereby state that: (Tick applicable option)

A. I have NO existing SSS Loan and will be able to submit any of the following proof:

❏ SSS ID
❏ SSS E1, E4 or E6
❏ Static Print Out of SSS Contributions
❏ Verification Slip (Mandatory)
❏ SSS Online Loan Statement of Account and Summary of Payments

B. I have an existing SSS Loan and will be submitting the following:

❏ SSS Statement of Loan

❏ Loan Verification Slip from SSS Office (with loan details - loan date, principal amount and
outstanding balance)

For this purpose, I am fully aware and acknowledge that Diane Pendle Inc. will deduct my
remaining balance amounting to Php ___________ from my salary within (Minimum deduction:
amount of monthly amortization based on the loan voucher).

❏ 24 Months (Maximum Term)

❏ Months (Indicate preferred number of Months) __________

C. Authority to Deduct

I hereby agree to pay my outstanding loan balance from SSS through payroll deductions. The
amount deducted shall be remitted by Diane Pendle Inc. to SSS for the monthly amortization of
my SSS loan.

I fully understand that any unpaid balance that has become due and demandable by SSS will
continue to incur penalties and interest until the outstanding loan balance is not fully paid and
Diane Pendle will not be liable for any penalties and interest that may incur from my unpaid
loan.

This waiver is being executed freely and voluntarily on this day of _______________.

___________________________________
Printed Full Name and Signature

__________________________________
SSS No. and Birthdate (DD/MM/YYYY)