AFFIDAVIT OF UNDERTAKING
(Non-Receipt of Advance Payment for Sickness/Maternity Benefit)
I, ______________________________________________________, of ________________ citizenship,
legal age, single/married, with residence/postal address at
____________________________________________________________________ and with Social
Security (SS)/Common Reference (CR) number ________________________, after having been sworn to in
accordance with law, hereby depose and state, that:
1. I, _________________________________________ , am a member of the Social Security System;
(Name)
2. I was an employee of ________________________________________________, with business
address at _____________________________________________, from __________________ and
was separated on _________________________________.
3. That I did not receive any advance payment of sickness/maternity benefit from my employer.
4. That I cannot secure a certificate of separation and non-advance payment of my sickness/maternity
benefit due to the reason/s stated below:
[ ] The company is on strike;
[ ] The company has been dissolved or has ceased operation;
[ ] I have a pending case before a court regarding my separation from employment;
[ ] I was separated from the company due to Absence Without Official Leave (AWOL);
[ ] With strained relations with my employer;
[ ] My current address is more than 30 kilometers from the employer’s address;
[ ] My record from the former employer is no longer available.
5. I undertake to return to SSS or to allow the necessary deduction from my future SSS benefits the full
amount I will receive in connection with this SS sickness/maternity benefit claim in case it is proven
that I have given false information;
6. I understand that I may be criminally liable for any false statement or misrepresentation made in this
document or in other documents submitted in connection with my claim; and
7. I am executing this affidavit to attest to the truthfulness, veracity and due execution of the foregoing
statements and this document.
In witness hereof, I hereby sign my name below on ___________________ in
_____________________________.
_________________________________
AFFIANT
(Signature Over Printed Name)
SUBSCRIBED AND SWORN to before me this ____ day of ___________, affiant having exhibited to me
his/her valid government-issued identification card/s ________________________________ issued on
____________________ at _______________________, Philippines.
SSS Administering Officer
(Signature Over Printed Name)
