REPUBLIC OF THE PHILIPPINES)

City/Municipality of Olongapo) S.S.

AFFIDAVIT OF SEPARATION FROM EMPLOYMENT

I, April Mae A. Pangomlayen of legal age, Filipino and residing at Block 6 Lot 20 Sta. Rita Village
Olongapo City, after having been sworn to in accordance with law hereby depose and state:

1. That I am a bonafide member of the Social Security System with SSS number 02-3577220-0.

2. That I was separated from my last employer, Super Value Inc. , with address at Magsaysay
Drive Corner Gordon Avenue, Olongapo City 2200 on 15th of August 2014 thereafter, I was never
again re-employed.

3. That I cannot secure a certification of separation from my last employer because the HR during
that time is already resigned and cannot retrieve the old records for the past 8 years.

4. That I am executing this affidavit to attest to the truth of the foregoing facts and to support my
Maternity Benefits Reimbursement.

April Mae A. Pangomalyen

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _____________ day of _____ 2023 in Olongapo
City, Philippines, affiant having exhibited to me his/her License No. C09-20-005104 issued in
Olongapo City on 20th of July 2020.

NOTARY PUBLIC

DOC NO. ____________

PAGE NO. ___________
BOOK NO. __________
SERIES OF ___________