REPUBLIC OF THE PHILIPPINES)

_______________________________ ) S.S.
AF F I D AV I T
I, _________________________________, of legal age, single/married, with residence and postal address
at _______________________________________________________________, after having been duly sworn to
in accordance with law, depose and state that:
I am a bonafide member/pensioner
______________________________;

of

the

Social

Security

Systm

under

SSS

No.

_____ I did not file with the SSS an application for ________________________________;
_____ I filed on _______________________ with the SSS __________________________ an
application
(Branch)
for ________________________ but to this date, have not received the check;
Verification from the SSS yielded the information that said application was duly approved and that PNB
check
no.
____________________
dated
_____________________
in
the
amount
of
_________________________ ( P ______________ ) was withdrawn by SSS in my name;
_____ I have neither received, endorsed, assigned nor appointed anybody to negotiate said check;
_____ I have received said check but it was lost / damaged on ______________________________ by
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Other infomation: ______________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________________.
I am executing this document to attest to the foregoing facts and to support my request for replacement /
deletion / transfer;
I will refund the total amount of the repalcement check should one be issued and submit myself to an
investigation and / or criminal prosecution in the event that the foregoing representations are found to be false;
IN WITNESS WHEREOF, I have hereunto affixed my signature this ______ day of ______________ at
___________________________, Philippines.

Telephone No. _________________

Mobile No.
_________________
Email address _________________

TIN

____________________________________
Affiant
________________________________

SUBSCRIBED AND SWORN TO BEFORE ME this ________ day of ____________________,

affiant exhibited to me his / her Community Tax Certificate No. ______________________ issued at
_____________________ on _______________________.

NOTARY PUBLIC
Doc. No.
Page No.
Book No.
Series of

_______
_______
_______
_______