REPUBLIC OF THE PHILIPPINES)

CITY
O F
L A P U L A P U) S.S
X ------------------------------------------------------/

AFFIDAVIT
I, JUAN DELA CRUZ, of legal age, Filipino, married, and a
resident of Pajo, Lapu-lapu City, Philippines, after having
been sworn to in accordance with law, do hereby depose and
state:
1.- I am a member of the Social Security System with
No. 66-12345-4;
2.- I
have
applied
for
Maternity
Claim
/
Reimbursement with the SSS and one of the requirements is
a certification of employment from my last employer,
Topmaster Manpower, with the effective date of my
separation from employment;
3.- I was an employee of Very Raw Human Resources
Corp. on June 2005. I transferred to Topmaster Manpower
Supply, Inc. on September 2005 and I quit my employment
on October 2005. My former employers cannot anymore be
located at their former addresses; hence, I cannot anymore
secure the required certification from it;
4.- Upon checking the records, the companies did not
appear to have filed a report with the SSS or pay all the
contributions that were deducted from my salary. Neither
did the companies advance any benefit by reason of, or on
occasion, of my confinement or after the date of my delivery;
5.- I am executing this affidavit in good faith and to
attest to the truthfulness of the foregoing statements in
support of my claim filed with the SSS.
IN WITNESS WHEREOF, I have hereunto set my hand
this 28th day of April 2015 at Lapu-lapu City, Philippines.
JUAN DELA CRUZ
Affiant
SUBSCRIBED AND SWORN to before me this 28 th day of April
2015 at Lapu-lapu City, Philippines, affiant exhibited to me his drivers
license (No. G06-14-12345) which is valid until January 29, 2017.
Doc No. ___

Page No. ___

Book No. ___
Series of 2015.