If your SSS Number’s current status is Prior Registrant or For Employment, and you want to change your SS Number’s status as Self Employed so that you will be allowed to starting paying your SSS Contribution, here’s the Affidavit of Source of Income Template that you can copy, fill up and print and present to the SSS Branch together with your SSS E4 – Change of Member Data Record Form. Make sure to notarize the filled up Affidavit of Source of Income before submitting to the SSS Branch.

Here’s the Affidavit of Source of Income Template.

Download PDF Sample here of Affidavit of Source of Income

AFFIDAVIT OF SOURCE OF INCOME

I, _________(state your name)___________, of legal age, Filipino, _____(state your civil status), presently residing at
_____(your address)_________________________ , and with SSS No. _(your ss number)____________,
after having been duly sworn in accordance with law, hereby depose and say:

1. That I am earning money by _____(state your source of income)_____________________________.
2. That I earn ___(elaborate the nature of your business)_____________________________
3. That my monthly income ranges from ___(state minimum amount you earn per month)______ pesos to ________(state max amount you earn per month)____ pesos.
4. That I am making this affidavit to to attest to the truth of the foregoing facts and to support my application for registration as Self-Employed Member of the SSS.
   

IN WITNESS THEREOF, I have hereunto affix my signature this ______(date)_____, in Quezon City, Philippines.

_________________

(Signature over printed name)

SUBSCRIBED AND SWORN before me this _ day of __________, in

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Here a sample filled up Affidavit of Source of Income for Independent Vendors (e.g Sari-sari store)

AFFIDAVIT OF SOURCE OF INCOME

I, JUANA SANTOS DELA CRUZ, of legal age, Filipino, married, presently residing at
20 SAMPAGUITA STREET KAMIAS, QUEZON CITY, and with SSS No. 0312345678,
after having been duly sworn in accordance with law, hereby depose and say:

1. That I am earning money as a Sari Sari store owner.
2. That I earn from selling different items in my mini store in our house.
3. That my monthly income ranges from 5,000 pesos to 6,000 pesos.
4. That I am making this affidavit to to attest to the truth of the foregoing facts and to
   support my application for registration as Self-Employed Member of the SSS.

IN WITNESS THEREOF, I have hereunto affix my signature this 1st day of November,
2018, in Quezon City, Philippines.

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JUANA SANTOS DELA CRUZ
SSS No. 0312345678
SUBSCRIBED AND SWORN before me this _ day of ___ 2013, in

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