Republic of the Philippines )

Camiling, Tarlac ) s.s.

AFFIDAVIT

I, ______________________, __ years old, Filipino citizen, single and a

resident of Barangay ___________________, Philippines, after having been
duly sworn to in accordance with law, do hereby depose and state THAT:

1. Sometime in July 201__, I hired ____________ (____, for brevity) as

our maid and subsequently, I enrolled her as a member of the Social
Security System (SSS);

2. However, due to misunderstandings as to the loss of money in my

wallet, I terminated __________ as our maid on September 201__;

3. After the separation from service of _________, I did not hire any
other maid or employed any other worker up to the present;

4. I am executing this affidavit to attest to the fact of the foregoing

statements and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 17th

day of November, 201___ at ___________, Philippines.

________________
Affiant

SUBSCRIBED AND SWORN to before me on the date and place

indicated above. Affiant exhibited before me her ____________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2016.