Академический Документы
Профессиональный Документы
Культура Документы
(02-2013)
NAME
(SURNAME)
LOCAL ADDRESS
(GIVEN NAME)
(SUFFIX)
(SUBDIVISION)
(MIDDLE NAME )
(BARANGAY/DISTRICT/LOCALITY)
(CITY/MUNICIPALITY)
MOBILE/CELLPHONE NO.
(STREET NAME)
(PROVINCE)
ZIP CODE
E-MAIL ADDRESS
COUNTRY
ZIP CODE
SS Total Disability
SS Death
EC Total Disability
(SUFFIX)
(SUFFIX)
EC Death
SS NO. OF MEMBER
PART II - QUESTIONNAIRE
1. For retirement pensioner, have you been re-employed/resumed self-employment ?
Yes
No
Yes
No
Date of marriage/cohabitation:
Yes
No
NAME OF GUARDIAN, IF
APPLICABLE
Yes
No
DATE OF
DATE OF MARRIAGE
EMPLOYMENT
SS NO.
DATE OF DEATH
1
2
3
4
5
I hereby certify that the foregoing information is complete, true and correct to the best of my knowledge.
DATE
RIGHT THUMB
RIGHT INDEX
(If unable to sign, affix fingerprints with the signature of two witnesses and
submit photocopy of one valid ID with photo and signature of each witness)
Witnesses to fingerprints:
1)
2)
SIGNATURE OVER PRINTED NAME
DATE
DATE
I certify that I have personal knowledge of the existence of the subject pensioner because he/she is my
and, furthermore, I attest to the veracity of the above information.
Pensioner is
living abroad
(relationship)
incapacitated.
POSITION
EE ID NO.
DEPARTMENT/BRANCH
SIGNATURE OVER PRINTED NAME OF SSS
OFFICIAL/REGULAR EMPLOYEE
Left
NOTICE:
Anyone who falsifies essential information requested by this or a related form may, upon conviction, be subject to fine and imprisonment
under the
law (Sec. 28 (a) of the Social Security Law and Art.207 (b) Chapter IX of PD # 626).
__________________________________________________________________________________________
DESIGNATION
DATE
DESIGNATION
DATE
APPROVED BY
For Retiree or
Total Disability
Pensioner, fill
out no. 1
For Survivor
Pensioner, fill
out nos. 1 &
For Pensioner
under a Guardian,
fill out nos. 1 & 3
2
3
ACKNOWLEDGEMENT RECEIPT
SS NUMBER OF PENSIONER
NAME OF PENSIONER
(SURNAME)
SS NUMBER OF MEMBER
NAME OF MEMBER
(SURNAME)
(GIVEN NAME)
(GIVEN NAME)
Please report for your Annual Confirmation anytime within your or member's birth month ; otherwise your pension will be suspended.
ISSUED BY:
SIGNATURE OVER PRINTED NAME
OF SSS /BANK PERSONNEL
DESIGNATION
DATE
ACKNOWLEDGEMENT RECEIPT
SS NUMBER OF PENSIONER
NAME OF PENSIONER
(SURNAME)
SS NUMBER OF MEMBER
NAME OF MEMBER
(SURNAME)
(GIVEN NAME)
(GIVEN NAME)
Please report for your Annual Confirmation anytime within your or member's birth month ; otherwise your pension will be suspended.
ISSUED BY:
SIGNATURE OVER PRINTED NAME
OF SSS /BANK PERSONNEL
DESIGNATION
DATE
ACKNOWLEDGEMENT RECEIPT
SS NUMBER OF PENSIONER
NAME OF PENSIONER
(SURNAME)
SS NUMBER OF MEMBER
NAME OF MEMBER
(SURNAME)
(GIVEN NAME)
(GIVEN NAME)
Please report for your Annual Confirmation anytime within your or member's birth month ; otherwise your pension will be suspended.
ISSUED BY:
SIGNATURE OVER PRINTED NAME
OF SSS /BANK PERSONNEL
DESIGNATION
DATE
ACKNOWLEDGEMENT RECEIPT
SS NUMBER OF PENSIONER
NAME OF PENSIONER
(SURNAME)
SS NUMBER OF MEMBER
NAME OF MEMBER
(SURNAME)
(GIVEN NAME)
(GIVEN NAME)
Please report for your Annual Confirmation anytime within your or member's birth month ; otherwise your pension will be suspended.
ISSUED BY:
SIGNATURE OVER PRINTED NAME
OF SSS /BANK PERSONNEL
DESIGNATION
DATE