Affidavit of Undertaking Template for Sickness/Maternity Benefit

Downloadable and Editable Template for SSS Affidavit of Undertaking Template for Sickness/Maternity Benefit

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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:

  1. I, __________________________ is a member of the Social (SSS) with SS Number/Common Reference Number ______________;
  2. 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 _______

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1 Comment on "Affidavit of Undertaking Template for Sickness/Maternity Benefit"

  1. Diana Martinez | November 10, 2022 at 6:39 am | Reply

    where i can send this affidavit of undertaking after? it has no section at portal and i can’t find email address

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