DATE

CERTIFICATION OF KASAMBAHAY FOR

QUARANTINE PASS

TO WHOM IT MAY CONCERN:

This is to certify that ______(kasambahay name)___________________ is connected

with our household located at _________(address of
household)_____________________________ as a kasambahay. ____(kasambahay
name)_____________________ is originally from ___(home of kasambahay)___ and this
certification is issued to him/her for purposes of securing a quarantine pass in order
to return safely to our household located at ______(address of household)______.

This certification is issued for whatever legal purpose it may serve and for
purposes of allowing her safe travels as she goes through the various checkpoints in
the different municipalities.

Certification issued by:

__(employer)____
Head of the Household
___(Address of the household)