DOLE Workers - Affidavit

FORM 4
Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT
National Capital Region
DOLE-NCR Building, 967 Maligaya St., Malate, Manila
REPUBLIC OF THE PHILIPPINES)

_________________________ )S.S.
AFFIDAVIT
I, ______________________________________, ____ years of age, single/married and residing at
_____________________________________________________, after having been sworn in accordance with law, depose and say:
1) I am working/employee of ____________________________________________________, located at

_____________________________________________________
2) The owner /president /manager of the Company is ___________________________________________________________
3) The nature of the Company’s / Employer’s business is:

 Retail  Agriculture
 Wholesale  Construction
 Service  Others: ___________________________________
 Manufacturing
4) I work as ____________________________________ and my work schedule is from ______ to _____, daily from _________
to _________; with a work schedule of ___________________________.
5) The current number of employees of the Company/Employer:

 less than 10 employees  10-50 employees
 51-199 employees  200 and above employees
6) Currently, my employment status is:

 Apprentice  Contractual  Others:
 Learner  Probationary _____________________________
 Casual  Regular
7) I started working in the Company / my Employer on ______________________________.
8) My salary/wage is computed on:

 Daily basis  Piece rate basis
 Commission basis  Others:
 Monthly basis _________________________________________
 Pakyaw basis
9) My daily salary rate/monthly salary/rate per piece is: ______________ with COLA of _____________
10) I receive my salary every: _______________________ of the month
11) I am / I am not given a copy of my pay slip and I receive/ I do not receive the net pay shown in the pay slip.
12) I received / I do not receive the net pay shown in the pay slip.
13) I am regularly given a meal break of ______ hours from __________ to ______________.
14) I work / I do not work / I sometimes work from 10:00 p.m. to 6:00 a.m. and I am / I am not paid the 10%
night shift differential pay.
15) I render / I do not render _________ hours of overtime work (work rendered in excess of 8 hours in a day):
_____ Every day ______ Others: ___________________________________________________________
16) I am paid / I am not paid for every hour of overtime work rendered on:
 Ordinary Days : Php ______________
 Rest Days : Php ______________
 Special Days : Php ______________
 Regular Days : Php ______________
17) I work / I do not work on:
_____ Special Holiday and I am paid / not paid additional amount equivalent to 30% on my daily pay.
_____ Regular Holiday and I am paid/ not paid additional amount equivalent to 200% of my daily pay.
18) I am paid / I am not paid my regular holiday pay.
19) I / _________________________ fills out my daily time records.
20) The Employer / Company provides / do not provide meal & snacks / lodging facilities and deduct _________
amount from my wage/ salary with / without written authority from me authorizing the deduction.
21) The following are deducted from my wage/salary:

 SSS : Php ______________
 Pag-ibig : Php _______________
 Philhealth : Php________________
 Others : Php ________________
22) I receive my wage/salary in: Cash / Check / thru ATM.
23) I enjoy / I do not enjoy any of the following leave benefit?

 5-days Service Incentive Leave
 60-78 days Maternity Leave
 5-days Service Incentive Leave pay
 7 days Paternity Leave
 7 days Solo Parent Leave
 60 days Special Leave for Women
 10 days Leave for Victims of Violence against Women and Children
24) There is / There is no labor union in the Company and I am / I am not a member of the union.
25) There is / There is no existing Collective Bargaining Agreement between the Union and Company.
26) I receive / I do not receive my 13th month pay.
27) In our workplace, there are:

 First Aider  Safety Officer
 Dentist  Doctor
 Nurse  Safety Practitioner
28) I further state/manifest the following: __________________________________________________________________________

______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
I hereby declare that the above were voluntarily given, true and correct to the best of my knowledge and
belief.
IN WITNESS HEREOF, I have hereunto affixed my signature this _______ day of __________, 20___ at
___________________.
______________________________
EMPLOYEE/ AFFIANT
(Signature & Printed Name)
SIGNED IN THE PRESENCE OF:
______________________________ ______________________________
SUBSCRIBED AND SWORN to before me this _____ day of _________________ , 20 _____ at ________________________.
________________________________________
Administering Officer

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FORM 4

Republic of the Philippines

REPUBLIC OF THE PHILIPPINES)

1) I am working/employee of ____________________________________________________, located at

2) The owner /president /manager of the Company is ___________________________________________________________

3) The nature of the Company’s / Employer’s business is:

5) The current number of employees of the Company/Employer:

6) Currently, my employment status is:

7) I started working in the Company / my Employer on ______________________________.

8) My salary/wage is computed on:

10) I receive my salary every: _______________________ of the month

18) I am paid / I am not paid my regular holiday pay.

19) I / _________________________ fills out my daily time records.

21) The following are deducted from my wage/salary:

22) I receive my wage/salary in: Cash / Check / thru ATM.

23) I enjoy / I do not enjoy any of the following leave benefit?

26) I receive / I do not receive my 13th month pay.

27) In our workplace, there are:

28) I further state/manifest the following: __________________________________________________________________________

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