REPUBLIC OF THE PHILIPPINES

CITY OF BATANGAS ) S.S.

AFFIDAVIT

I, _______________________, single, of legal age, and a resident of Soro Soro

Ibaba, Batangas City, after being duly sworn to in accordance with law, depose and state
THAT:

1. I am a member of Social Security System (SSS) with SS Number

_______________________

2. I started working as a contractual at St. Camillus De Lellis Hospital last November

26, 2022;

3. Upon reviewing my SSS Portal, I discovered that I have contributions from the
year 2015 up to 2016 from Kabraso Multi-Purpose Cooperative with Employer
ID _______________________;
Copy is hereto attached as Annex “A”.

4. I am executing this Affidavit to attest to the fact that I am not an employee of

Kabraso Multi-Purpose Cooperative and during that time, I am still a student at
Batangas State University;

5. Also, I am executing this Affidavit to request the SSS Batangas City Branch to
remove the aforesaid contributions in my account and for whatever legal purposes
this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of

______________ 2022 at Batangas City, Philippines.
Afffiant

SUBCRIBED AND SWORN TO before me this ___ day of

_______________ 2023 at Batangas City, affiant exhibiting to me her Driver’s License
No. ____________________.

Doc. No. _____;

Page No. ____;
Book No. ____;
Series of 2023.