REPUBLIC OF THE PHILIPPINES )

ANGELES CITY ) S.S.

AFFIDAVIT

I, _________________, of legal age, Filipino, and a resident of _______________, after

having been duly sworn in accordance with law, hereby depose and state that:

1. I am an employee of ______________ and a bona fide member of Social Security

System (hereinafter referred to as the SSS).

2. On ______________, I was married to __________________ and had one child,

________________ who was born on _______________ and then shortly went into separation.

3. I then had a common law union with ___________________ with whom I bore
one child and availed of maternity benefits.

4. On __________________, I bore my second with the said _________________.

5. I am executing this affidavit to attest to the truth of the foregoing statement, and
for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand on this _____ day of

________________, in Angeles City, Philippines.

___________________
Affiant

SUBSCRIBED AND SWORN TO before me, in the City of Angeles and the Province of
Pampanga, this _____ day of _______________, by _________________, personally known to me,
who is the same person who personally signed before me the foregoing affidavit and
acknowledged that he/she executed the same.

Doc. No.
Page No.
Book No.
Series of 2016.