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 andresiding at ______________________________________ after having been swornto in accordance with law hereby depose and state:

1. That I am a bonafide member of the Social SecuritySystem wi th 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 cer t i f i ca t ion o f separat ionfrom my last employer because ________________________

4. That I am execut ing th is a ff idav i t to a t tes t to thetruth 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 havingexhibited to me his/her Residence Certificate No. __________________________________ issued in _________________________ on ________20_________.

Notary PublicUntil December 31, 20 ___PTR No. _____________Issued at _____________Issued on _____________DOC NO. ____________

PAGE NO. ____________BOOK NO. ____________SERIES OF ____________