REPUBLIC OF THE PHILIPPINES )
City/Municipality of ____________ )
___________________________ ) S.S.
Province of __________________ )
SSS Form E-417
AFFIDAVIT OF SEPARATION FROM EMPLOYMENT
I, _________________________ of legal age _________________ Filipino and
residing at ______________________________________ after having been sworn
to in accordance with law hereby depose and state:
1. That I am a bonafide member of the Social Security
System with SSS number _______________________
2. That I was separated from my last employer, _____________
____________________, with address at ________________
____________________ on _______________ thereafter,
I was never again re-employed.
3. That I cannot secure a certification of separation
from my last employer because ________________________
4. That I am executing this affidavit to attest to the
truth of the foregoing facts and to support my
________________________________________________.
FURTHER AFFIANT SAYETH NAUGHT.
Affiant
SUBSCRIBED AND SWORN TO BEFORE ME this _____________ day of
_____ 20___ in Quezon City, Philippines, affiant having
exhibited to me his/her Residence Certificate No. ___________________
_______________ issued in _________________________ on ________
20_________.
Notary Public
Until December 31, 20 ___
PTR No. _____________
Issued at _____________
Issued on _____________
DOC NO. ____________
PAGE NO. ____________
BOOK NO. ____________
SERIES OF ____________
