Republic of the Philippines )

City/Municipality of __________ )
Province of_________________) S.S.

AFFIDAVIT
(of Declaration of Source of Income)

I, ________________________________, with Social Security No. ________________,

(Complete Name of Affiant)
Filipino, __________________, of legal age, and with residence adddress at _______________
(Civil Status)
___________________________________, after having been sworn to in accordance with law,
(Complete Residence Address of Affiant)
hereby depose and state: THAT

1. I am self-employed as I have no employer other than myself and derive income from my
physical and mental efforts as:

_______________________ from _________ until _________ at _______________________.

(Nature of Self-Employment) (Start) (End) (Where Conducted)

2. Should SSS determine any mispresentation as to my statements in this Affidavit or should

SSS find that I am not qualified to be registered as self-employed member, I agree that my
SSS membership registration as well as entitlement to all SSS benefits shall be revoked and all
my remitted contributions shall be refunded.

3. I have read and understood the contents herein and swear under the penalty or Perjury
pursuant to Article 183 of the Revised Penal Code; and Falsification pursuant to Section 28 (a)
of RA 1161, as amended (Social Security Law).

4. I am executing this Affidavit to attest to the truth of the foregoing and for the purpose of
applying for late registration as a Self-Employed SSS Member.

IN WITNESS WHEREOF, I have hereunto set my hand this _________________day of

_______________, 2017 in ____________________________, Philippines.

___________________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this ____ day of _________, Affiant

exhibiting to me his/her Community Tax Certificate No. ______________, issued on ________
at ___________________ and __________ ID No. ______________ issued on ____________
in _________________.

NOTARY PUBLIC
Doc. No. _____;
Page No. ____;
Book No. ____;
Series of ____.