SSS Form E-417 –A

AFFIDAVIT OF SEPARATION FROM EMPLOYMENT/SELF-EMPLOYMENT

I, ____________________________Filipino, married/single/separated/divorced, of legal age and

residing at _____________________________________________ after having been sworn to in
accordance with the law hereby depose and state:

1. That I am a bonafide member of the Philippine Social Security System with SSS number
___________________________

2. That I was separated from my last employer, __________________________

___________________________, with address at ______________________
___________________________ on ________________________ therafter, I was never
again re-employed in the Philippines and ceased employment whatsoever in the United
Kingdom effective _____________________ .

3. That I cannot secure a certification of separation from my last employer in the Philippines
because __________________________________.

4. That my declared business for self-employment at

_____________________________________________ has ceased operation as per
attached certification from Barangay in ___________________________________________
dated _________________.

5. That I have stopped practicing my profession as ____________________________ effective

_______________________ because ______________________________.

6. That I am executing this Affidavit to attest to the truth of the foregoing facts and to support
my application for retirement benefit.

FURTHER AFFIANT SAYETH NAUGHT.

__________________
Affiant

ATTESTED/PROCESSED BY:

SSS Representative, London

IDs Presented
□ SSS No. ______________
□ Freedom Pass
□ Passport No._________________

Issued at _____________ on _____________ and valid until _____________