Republic of the Philippines )

Province of Negros Oriental ) s.s

CITY OF CANLAON
)

AFFIDAVIT OF NON-RECEIPT OF MATERNITY CHECK

I, GINA TABORADA CABARROBIAS, 26 years old, Filipino, single and a resident of
Barangay Panubigan, Canlaon City, Negros Oriental, after having been duly sworn to in
accordance with law, do hereby depose and say:
That I am a member of the Social Security System (SSS) per my SS Number 0632394498;
That on August 29, 2013, I was admitted in the Salvacion Oppus Yiguez Memorial
Provincial Hospital, Maasin City Southern Leyte, because, as a single parent or unmarried,
begot or delivered from my womb my only first (Ist) male child (son) who is named as
JOSHREY GIN CABARROBIAS CELESTE who was born on August 29, 2013 at Salvacion
Oppus Yiguez Memorial Provincial Hospital, Maasin City Southern Leyte;
That as a member of the Social Security System (SSS), I was entitled of a MATERNITY
BENEFIT;
That upon approval of my MATERNITY BENEFIT at the SSS, Mandaue City, Cebu, a
Check No.0010724625 in the amount of SEVENTEEN THOUSAND THREE HUNDRED
THIRTY THREE AND THIRTY THREE CENTAVOS (17,333.33) with Settlement Date 10-152014 was issued in my favor; and was sent through the Bureau of Post Office in Canlaon City,
Negros Oriental. However, when I inquired in the Bureau of Post Office of Canlaon City, Negros
Oriental, I was informed by the Head or Personnel of the Bureau of Post here in Canlaon City,
Negros Oriental, that my said MATERNITY BENEFIT CHECK NO. 0010724625 in the amount
of Php 17,333.33 was returned back to the SSS, Mandaue City, Cebu because the said Post
Office could not locate me where I stayed here in my address in Panubigan, Canlaon City,
Negros Oriental; and that on my part, I was not able to personally receive my said MATERNITY
BENEFIT CHECK NO. 0010724625;
That I am executing this affidavit in order to attest the truth of the foregoing facts on
narrated on declared above especially the facts that I was not able to receive my MATERNITY
BENEFIT CHECK. This is also executed for whatever legal purposes this may come best.
IN WITNESS WHEREOF, I have here unto affixed my signature this
2015 at Canlaon City, Negros Oriental, Philippines.

day of March,

GINA TABORADA CABARROBIA

(Affidavit)
UMID ID No.CRN-0111-3447947-D
Issued of the SSS, GSIS & Pag-ibig

SUBSCRIBED AND SWORN to before me this

day of March, 2015 at Canlaon City,
Negros Oriental, Philippines. Said affidavit exhibited her valid ID number as shown above and
written below her printed name and signature.