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E-417 affidavid for separation of employment
Separation of Employment affidavit for Retirement Claim
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REPUBLIC OF THE PHILIPPINES
City/Municipality of ____________
___________________________
Province of __________________
)
)
) S.S.
)
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.
T h a t I a m e x e c u t i n g t h i s a ff i d a v i t t o a t t e s t t o t h e
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_________.
DOC NO.
PAGE NO.
BOOK NO.
SERIES OF
____________
____________
____________
____________
Notary Public
Until December 31, 20 ___
PTR No. _____________
Issued at _____________
Issued on _____________
