Affidavit To Cancel Previous Sss #

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REPUBLIC OF THE PHILIPPINES)

CITY OF TAGBILARAN ) S. S.

AFFIDAVIT

I, JESSELOU G. GAMIL, Filipino, of legal age, single and a resident of Banban, Dimiao, Bohol, after
having been sworn in accordance with law, hereby depose and say:

1. That I a bona fide member of the SOCIAL SECURITY SYSTEM (SSS) with SSS No. 06-2712235-
8 having been employed by Ms. Julie Lacson Ambrona as domestic helper in the year 2007;

2. That as such, my former employer paid to the SSS my monthly contributions for the months of
November 2007 and December 2007;

3. That I have ceased working with my former employer and desire to continue paying my monthly
contributions with the SSS as self-employed using my abovementioned SSS number, and in this connection,
I am requesting the SSS to cancel my monthly contributions for the months of November 2007 and
December 2007;

4. That I execute this affidavit voluntarily to attest and to the truth of the foregoing statements for
whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 19 th day, of April, 2010, at Tagbilaran
City, Bohol, Philippines.

JESSELOU G. GAMIL
Affiant

SUBSCRIBED AND SWORN to before me this 19 th day, of April, 2010, at Tagbilaran City, Bohol,
Philippines, Affiant exhibiting to me her Postal I. D. bearing her signature and picture.

ATTY. THADDEUS JOSE C. ACERO


Notary Public
Until December 31, 2010
Attorney’s Roll No. 23931
PTR # 7087371, 1-2-09, Valencia, Bohol
IBP # 711129, 11-24-08, TIN 126-371-455

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