SIC – 01247 (12-2015)
Republic of the Philippines )
City/Municipality of _________) S.S.
Province of ________________)
AFFIDAVIT OF UNDERTAKING
(Sickness/Maternity Benefit Claim)
I, _______________________________________________, of legal age, ________________ citizen, signgle/married, with addres at ____________________________________________,
after having been sworn in accordance with law, hereby depose and state, that:
- I, __________________________ is a member of the Social (SSS) with SS Number/Common Reference Number ______________;
- I was an employee of ________________________, with business address at _______________________________________________________________, from ______________________ and was separated on _________________;
(MM/DD/YYYY) (MM/DD/YYYY)
- That I cannot secure a certificate of separation and non-advance sickness/maternity benefit due to the reason/s stated below:
[ ] The company is on strike.
[ ] I have a pending labor case with the company.
[ ] Company has ceased operation.
[ ] I was separated from the company due to Absence Without Official Leave (AWOL).
[ ] With strained relations with my employen
[ ] Others (Please specify) ___________________________
- In case it is proven that I have given false information, I undertake to return or to be deducted from future benefits due me in full the amount I have received from the SSS;
- I am aware that I may be criminally liable for any false statement or representation made
in this document or for any other documents submitted in connection with my claim; and
- I am executing this affidavit to attest to the truthfulness, veracity and due execution of the
foregoing statements and this document.
Affiant further sayeth naught.
_______________________, ______________________________________________.
(Date) (Place)
___________________________
AFFIANT
(Signature over Printed name)
SUBSCRIBED AND SWORN to me this _______ day of _________ 20 ________, affiant exhibiting to me his/her Community Tax No ____________________ issued on ___________ at _________________ and Identification Card with No. __________ issued by ____________ on _________/ valid until ______________.
Notary Public
Doc. No. ____________
page No. ____________
Book No. __________
Series 20 _______
Related Articles:
- How to Apply and Qualify for SSS Maternity Benefit
- Frequently Asked Question about SSS Maternity Benefit
- How to Know How Much is your SSS Maternity Benefit
- Common reasons why your SSS Maternity Benefit is denied
- Affidavit of Undertaking Template
- How to Comply with Disbursement Account Enrollment Module?
- How to Submit SSS Maternity Application (MAT2) in SSS Website for Self Employed, Voluntary, OFW, Non Working Spouse and Separated from Employers?
- How to File for SSS Maternity Reimbursement for Regular and Household Employer?
where i can send this affidavit of undertaking after? it has no section at portal and i can’t find email address