Republic of the Philippines )

Municipality of Dapa )S.S

AFFIDAVIT OF SETTLEMENT

WE, _________________-A, Filipino, of legal ages, and residents of _________________, after

having been sworn to in accordance with law hereby depose and state that:

1. Sometime on December 14, 2018 in the morning, some employees of Department

of Labor and Employment or DOLE for brevity conducted a Routine
Inspection at ________________, where we are currently em-
ployed;

2. As a consequence thereto, some violations were discovered including the aspect of

non-compliance with Labor Standards specifically on the matter of
underpayment of wages among others;

3. Subsequently our employer was directed to rectify the same, and settle the under-
paid wages to their concerned employees as per the Labor Inspector’s
findings;

4. As such, we had a meeting with our employer regarding this concern, and they have
rigorously explained to us the findings made by DOLE and assured
us that the same will be corrected and implemented;

5. Hence, we voluntarily execute this affidavit to prove that we are aware of our rights
as employees, and that we caused the preparation of this Affidavit of
Settlement since we have already been paid the amount due to each one
of us as determined by DOLE pursuant to law and regulations;

6. We herein attest to the truthfulness of the foregoing facts for whatever lawful pur-
pose it may serve.

IN WITNESS WHEREOF, We hereby affix our signature this ____ day of _______________ in
the ______________________.

SUBSCRIBED AND SWORN to before me, a Notary Public, this ______________________ at

__________________, affiants exhibiting to me their valid ID as competent and credible proof of
their identity.

NAME ID ISSUED ON/AT