REPUBLIC OF THE PHILIPPINE]

CITY OF SORSOGON ] SS.

AFFIDAVIT OF DECLARATION OF SOURCE OF INCOME

I, CHRISTOPHER C. GAJULTOS, of legal age, single and presently

residing at #247 Rizal St., Barangay Sirangan, Sorsogon City, after being duly
sworn to in accordance with law, DEPOSE and STATE:

1. That am a Self-employed as I have no other employer other

than myself and derive income from my physical and mental
efforts, as: an employee in a certain rice retail establishment at CGG
Store located in Market Site Sirangan, Sorsogon City from January
2016 to August 2016;

2. I became a bona fide member of the Social Security System

[SSS], Sorsogon Branch, under SSS No. 05-1277949-2, but due to
lack of work I failed to pay its monthly dues;

3. That as of today I am gainfully employed as an employee of

ROPALI, through an agency, as such they are requiring from me an
evidence that I am an SSS Member;

4. Therefore, I am humbly requesting the SSS to change the

entry of my SSS status from Self-Employed status to “Employed”
status by reason of my gainful employment;

5. I have read and understood the contents herein and swear

under the penalty of Perjury pursuant to Article 183 of the Revised
Penal Code and Falsification pursuant to Sec. 28 (a) of R.A. 1161, as
amended (Social Security Law);

6. I am executing this Affidavit to attest to the truth of the

foregoing fact and for the SSS to make the necessary correction.

IN WITNESS WHEREOF, I have hereunto set my hand, this 15th

day of August, 2019 in the City of Sorsogon, Philippines.

CHRISTOPHER C. GAJULTOS
Affiant

SUBCRIBED AND SWORN to before me, this 15th day of August,

2019, in the City of Sorsogon, Philippines, affiant exhibiting to me his
government issued PhilHealth ID No. 10-025343112-6, issued by the Philippine
Health Insurance Commission, with a signature and photograph in his likeness.

Doc. No. ____;

Page No.____;
Book No.____: NOTARY PUBLIC
Series of 2019.