Republic of the Philippines )

Province of Southern Leyte ) S. S.

C I T Y OF M A A S I N )
X------------------X

AFFIDAVIT

I, _________________________, of legal age, Filipino, married and

a resident of ______________________________________________,
after having been duly sworn to in accordance with law, do hereby depose
and say: That –

I am an employee at ____________________________ starting from

____________ up to present;

On _______________, I was absent from work because

_______________________________________________________; I felt
weak and I needed to take some rest;

I am executing this affidavit to attest to all the above facts and for
whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_______________ 2018 at Maasin City, Southern Leyte, Philippines.

________________________
Affiant
ID No. __________________

SUBSCRIBED AND SWORN to before me

this ______________ 2018 at Maasin City, Southern Leyte, Philippines.

Doc. No. ______;

Page No. ______;
Book No. _____;
Series of 2018.