Affidavit of Undertaking Template for Sickness/Maternity Benefit

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

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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• 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?