REPUBLIC OF THE PHILIPPINES )

PROVINCE OF NUEVA VIZCAYA )S.S.

MUNICIPALITY OF BAYOMBONG)

AFFIDAVIT OF OWNER
(RE: SEPARATION OF EMPLOYEE)

I, JASMINE B. DE GUZMAN, of legal age, single, Filipino, and a resident of

Villaflores, Santa Fe, Nueva Vizcaya, after having been duly sworn to in accordance with
law, do hereby depose and state:

1. That I am the owner of JEMS PHARMACY, a business located at Almaguer North,

Bambang, Nueva Vizcaya;

2. That JEMS PHARMACY has the Employer ID No. 8001458954 and we are
registered at the SSS Solano Branch, Solano, Nueva Vizcaya;

3. That an employee under the name of CARMELITA UPAY is no longer

connected to JEMS PHARMACY;

4. That said employee did not disclose such overdue loans to us as she were
incurred before she were employed at JEMS PHARMACY;

5. That I am aware of the nature, consequences and incurring liabilities for any
falsity, deceit, fraud, misinterpretation or non-disclosure made in connection with
reporting separation of said employee under the applicable laws, rules and
regulations;

6. That I am executing this declaration for the Social Security System with the
purpose of removing the said employee as she has been separated from JEMS
PHARMACY long before.

IN WITNESS WHEREOF, I hereby set my hand this 12 th day of January, 2022, at

Bayombong, Nueva Vizcaya.

JASMINE B. DE GUZMAN
Affiant
CEI: UMID CRN-0111-6227024-3

SUBSCRIBED and SWORN TO ME before this 12 th day January, 2022, at Bayombong,

Nueva Vizcaya, affiant personally known to me to be the same person who executed
the foregoing affidavit.