REPUBLIC OF THE PHILIPPINES )

PROVINCE OF TARLAC ) S.S.

MUNICIPALITY OF CAMILING )

AFFIDAVIT
I, JUAN DELA CRUZ, 105 years old, Filipino citizen and a resident of
Barangay Barangay, after having been duly sworn to in accordance with law,
do hereby depose and state THAT:

1. I became a member of the Social Security System (SSS) when I

engaged myself as a vendor;

2. However, starting January 1, 1666, due to health reasons and old

age, I ceased to work as vendor and no longer engaged in any
gainful occupation up to present;

3. I am executing this Affidavit in support my retirement claim from the

SSS;

4. Finally, I am executing this Affidavit to attest to the truth of the

foregoing statements and for all legal intents and purposes it may
serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 30th

day of January, 1666 at Camiling, Tarlac, Philippines.

JUAN
Affiant

SUBSCRIBED AND SWORN to before me on the date and place

indicated above. Affiant exhibited before me his SSS I.D. bearing his SS No.
00-000000-0 issued by the Social Security System.