stDOMINIC ORMEDICAL CENTER Our Hearts Listen UNDERTAKING AND WAIVER FOR SSS/HDMF LOAN DEDUCTION . Filipino, of legal age, with address at . do hereby represent that all statements ‘made herein are true and | commit and undertake to perform all of the following: 1. 1am a former employee of St. Dominic Medical Center, Inc. The effectivity of my resignation is on ; Ihave an existing SSS and/or HDMF loan at the time of my resignation; 'hereby specifically authorize St. Dominic Medical Center, Inc. through its duly authorized representative not to deduet from my final pay my SSS and/or HDMF loan balance; 4. The said loan/s will be settled through: Continuation of the salary deduction through my new employer Personal remittance 5. My former company, St. Dominic Medical Center, Inc., will not be held liable for any past due loan, if any, as soon as my employment ends with the company in connection with the undertaking | committed above. ‘Signature Over Printed Name/Date (Attach a valid government-issued ID)