Republic of the Philippines )

City/lvlunicipality of )
Province of ) S.S.

AFFIDAVIT
" (of Declaration of Source of Income)

I, with Social Security No.

tComplete Name ofAfianh
Filipino, of legal age, and with residence address at
tCivil Sonst
after having been swom to in accordance
tCamplete Residence Address ol Affiantt
with law, hereby depose and state: THAT -

l. I ary self-employed as I have no employer other than myself and derive income from my
physical and mental effiorts as:

from until at
lW tst.rh ,Ed, d{here Conducted

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

SSS find that I am not qualilied 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 of Perjury
pursuant to Article 183 of the Revised Penal Code; and. FatsiJication pwsuant 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

_,20 in Philippines.

AfFrant

SUBSCRIBE AND SWORN to before me _ day of this _, Affiant exhibited to

me hisllter CTC No. issued * _
at and ID No. issued on
in

NOTARY PUBLIC
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