How to write a statement of non-payment of social security

If an employee proposes not to participate in social security, the employee must personally write a certification document and handprint on the signature. The format of the certificate is as follows:

Certification

I xxx, male/female, identity card number, in xx years xx months xx in xxxxxx company work, because of personal reasons, do not want to let xxxxxx company for me to buy old age, unemployment, maternity, work injuries, medical care, and other five social insurance, I would like to take all the responsibility for this.

This is hereby certified!

xxx

Year month day