REPUBLIC OF THE PHILIPPINES )

PROVINCE OF BATANGAS )
STO. TOMAS, BATANGAS ) S.S.

AFFIDAVIT OF SEPARATION FROM EMPLOYMENT / CESSATION OF SELF-

EMPLOYMENT WITH UNDERTAKING
(re: SSS Retirement Benefit)

I, ERLINDA G. SANCHEZ, both of legal ages, Filipino, married and presently

residing at San Agustin, Sto. Tomas, Batangas, after having been duly subscribed to in
accordance with law, hereby depose and state THAT;

1. That I am a bona fide member of the Social Security System (SSS) with assigned SS
Number 04-0309814-3;

2. That I was separated from my last employers/s _____________ with office

address/es at ______________________ on ______________________ and was never
agin re-employed/re-engaged in self-employment;

3. That I cannot secure a certification and/or proofs from my last employment/self-

employment because ___________________________________________;

4. That I am aware of the nature, consequences, and incurring liabilities

(criminal/civil/administrative) for any falsity, deceit, fraud, misrepresentation or non-
disclosure made in connection with my claim/application for retirement benefits under the SS
Law and other applicable laws, rules and regulations;

5. That I hereby undertake to inform/notify SSS on the fact of my re-employment/re-

engagement in self-employment after availing of retirement benefits; and

6. I am executing the foregoing affidavit to attest to the truthfulness of the foregoing

facts and to support my claim/application for retirement benefits.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

______________ at Sto. Tomas, Batangas.

ERLINDA G. SANCHEZ
Affiant

SUBSCRIBED AND SWORN to before me this _____________ at Sto. Tomas,

Batangas, affiants exhibiting to me her competent evidence of identity: SSS ID WITH NO.
04-0309814-3.

ARTH JHUN A. MARASIGAN

NOTARY PUBLIC
UNTIL DECEMBER 31, 2019
PTR NO. 21635686 01/03/2019 STO. TOMAS, BATANGAS
IBP LIFE NO. 07648 / ROLL NO. 49621
Unit No. 1, Mt. View Subd. Mayapis Avenue
Tanauan City, 4232
Tel No. (043) 7787098

Doc. No. _____

Page No. _____
Book No. _____
Series of 2018.