Republic of the Philippines)

City of ________________) S.S.

AFFIDAVIT OF UNDERTAKING
(Sickness/Maternity Benefit Claim)

I, CHEDRIX DELA ROSA CALARA, Filipino, of legal age, married, and a

resident of No. 11 Arandia St., Bismac Homes, Tunasan, Muntinlupa City, after having
been duly sworn, do hereby depose and state, that:

1. I am a member of the Social Security System (SSS) with SS

Number/Common Reference Number __________________________;

2. I was an employee of FIELDMEN GENERAL SERVICES

CORPORATION/FIELDMEN JANITORIAL SERVICES CORPORATION with
business address at 1040-A Teresa St., Brgy. Valenzuela, Rizal Village, Makati City 1208
from April 1, 2001 and was illegally separated on April 24, 2018;

3. I cannot secure a certificate of separation and non-advance payment of my

sickness/maternity benefit because I have a pending labor case against the company
docketed as CHEDRIX DELA ROSA CALARA vs. FIELDMEN GENERAL SERVICES
CORP./FIELDMEN JANITORIAL SERVICES CORP./(1) EMILIA M. HERNANDEZ (2)
GINA DULAY (3) ELISA G. SANTOS, and (4) TERESA ARGUELLES (NLRC CASE NO.
NCR-05-08664-18);

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 the 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.

IN WITNESS WHEREOF, I hereunto affixed my signature this

__________________ 2019 here in _____________________, Philippines.

CHEDRIX DELA ROSA CALARA

Affiant
SSS ID No. ___________________________

SUBSCRIBED AND SWORN to before me this _______________________here

in __________________, Philippines. Affiant exhibited to me his government-issued I.D.
with numbers indicated above to prove and establish his personal identity.

Doc No. _____;

Page No. _____;
Book No. _____;
Series of 2019.