City of Bacolod …………..)s.s.

x---------------------------------x

AFFIDAVIT OF SEPARATION

I, __________, of legal age, Filipino, married and a resident of _________________,

Philippines, after having been sworn to an oath, do hereby depose and say:

That I was the employer of _____________, as household employees ;

That ___________ was employed with me on ___________, while ______________ was

also employed with me on _____________ ;

That ___________ was registered with Social Security System with SSS No.
___________, while __________________ was also registered with Social Security with SSS
No. __________

That I am executing this Affidavit to attest to the veracity of the foregoing fact;

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

______________________________, Bacolod City, Philippines.

______________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of _____________, at

Bacolod City, by _____________, who has satisfactorily proven to me her SSS ID No.
___________________________ that she is the same person who personally signed the
foregoing affidavit of separation before me and acknowledged that she executed the same.

WITNESS MY HAND AND SEAL on the date and in the place above written.

Doc. No. _____ ;

Page No. _____ ;
Book No. ____ ;
Series of 20_____.