SSS Affidavit of Undertaking
By KD On 2/09/2016
At last, SSS has issued a form for an Affidavit of Undertaking for SSS members who cannot get a Certificate of Separation and Non-advancement of SSS Maternity Benefit from their employers due to certain reasons like being AWOL.
Click this Affidavit of Undertaking to download the form.
This is how the Affidavit of Undertaking appears:
SIC - 01247 (12-2015)
Republic of the Philippines )
City/Municipality of __________) S.S.
Province of _________________)
AFFIDAVIT OF UNDERTAKING
(Sickness/Maternity Benefit Claim)
I, _____________________________________________, of legal age,
_______________ citizen, single/married, with address at
after having been sworn in accordance with law, hereby depose and state, that:
1. I, _______________________ is a member of the Social Security System
(SSS) with SS Number/Common Reference Number _________________;
2. I was an employee of ______________________________, with business
address at ___________________________________________ __, from
_________________________and was separated on _______________;
3. That I cannot secure a certificate of separation and non-advance payment
of my sickness/maternity benefit due to the reason/s stated below:
[ ] The company is on strike.
[ ] I have a pending labor case with the company.
[ ] Company has ceased operation.
[ ] I was separated from the company due to Absence Without Official
[ ] With strained relations with my employer.
[ ] Others (Please specify) _____________________________________
4. In case it is proven that I have given false information, I undertake to return
or to be deducted from future benefits due me in full the amount I have received
from the SSS;
5. I am aware that I may be criminally liable for any false statement or representation
made in this document or for any other documents submitted in connection with
my claim, and
6. I am executing this affidavit to attest to the truthfulness, veracity and due execution
of the foregoing statements and this document.
Affiant further sayeth naught.
(Signature over Printed Name)
SUBSCRIBED AND SWORN to me this ____________day of ____________ 20___,
affiant exhibiting to me his/her Community Tax Certificate No. ______________
issued on _______________ at _________________ and Identification Card with No.
_______________________issued by __________________ on ___________________
valid until _____________________.
Doc. No. ______________
Page No. ______________
Book No. ______________
Series of 20 __________