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					                                                                                             SSS Form E-417
REPUBLIC OF THE PHILIPPINES            )
City/Municipality of ____________       )
___________________________            ) S.S.
Province of __________________         )

                   AFFIDAVIT OF SEPARATION FROM EMPLOYMENT

     I, _________________________ of legal age _________________ Filipino and
     residing at ______________________________________ after having been sworn
     to in accordance with law hereby depose and state:
             1.    That I am a bonafide member of the Social Security
                   System with SSS number _______________________

             2.    That I was separated from my last employer, _____________
                   ____________________, with address at ________________
                   ____________________ on _______________ thereafter,
                   I was never again re-employed.

             3.    That I cannot secure a certification of separation
                   from my last employer because ________________________

             4.    T h a t I a m e x e c u t i n g t h i s a ff i d a v i t t o a t t e s t t o t h e
                   truth of the foregoing facts and to support my
                   ________________________________________________.
                   FURTHER AFFIANT SAYETH NAUGHT.




                                                                                Affiant
       SUBSCRIBED AND SWORN TO BEFORE ME this _____________ day of
       _____ 20___ in Quezon City, Philippines, affiant having
       exhibited to me his/her Residence Certificate No. ___________________
       _______________ issued in _________________________ on ________
       20_________.


                                                                         Notary Public
                                                                Until December 31, 20 ___
                                                                PTR No. _____________
                                                                Issued at _____________
      DOC NO.     ____________                                  Issued on _____________
      PAGE NO.    ____________
      BOOK NO.    ____________
      SERIES OF   ____________

				
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Description: health insurance