Republic of the Philippines

SOCIAL SECURITY SYSTEM

RETIREMENT CLAIM APPLICATION
(04-2012)
PART 1 Please read the instructions at the back of the form before filling-up the application. Print information in capital letters and use black ink only.
MEMBER’S INFORMATION
SS NUMBER NAME OF MEMBER (Surname) (Given Name) (Middle Name)

0 3 3 7 3 8 2 2 4 2 MORONIA BENJAMIN JR. MAGKASI

ADDRESS (Number, Street and Subdivision) (Barangay) (Town/District) (City/Province) POSTAL CODE
L8 B21 MAKILING ST., Mt VIEW SUBD., MUZON CITY OF SAN JOSE DEL MONTE BULACAN 3 0 2 3
DATE OF BIRTH (mm-dd-yyyy) PLACE OF BIRTH (Town/District) (City/Province) GENDER

0 5 2 7 1 9 5 8 MEYCAUAYAN, BULACAN x Male Female

CIVIL STATUS TIN TELEPHONE (IncludingAreaCode) / MOBILE NO.
Single Legally Separate d
Married Widow/Widower 1 2 3 1 6 1 0 4 6 0 9 3 2 1 2 1 5 9 1

PERIOD OF EMPLOYMENT (mm-yyyy)

NAME OF EMPLOYER ADDRESS
From To
1.COLEGIO DE STO NINO MEYCAUAYAN CORP

2.

3.

4.

DEPENDENT CHILDREN (Below 21 years old or above 21 but incapacitated)

CHECK APPLICABLE
DATE OF BIRTH COLUMN
NAME OF CHILDREN ADDRESS
(mm-dd-yyyy) Legitimate Illegitimate

1. N/A

2.

3.

4.

5.
DO YOU WANT TO RECEIVE THE FIRST 18 ARE YOU CURRENTLY RECEIVING SSS IF YES, CHECK TYPE OF PENSION
MONTHLY PENSION IN ADVANCE? PENSION?

Yes No Yes No Disability Death

IF RECEIVING PENSION UNDER DEATH, INDICATE SS NUMBER AND NAME OF DECEASED MEMBER:
SS NUMBER NAME OF MEMBER (Surname) (Given Name) (Middle Name)

PERFORATE HERE
RECEIVED BY:
SOCIAL SECURITY SYSTEM
RETIREMENT CLAIM APPLICATION
ACKNOWLEDGMENT STUB
(04-2012) SIGNATURE OVER PRINTED NAME DATE
PLEASE PRESENT THIS WHEN INQUIRING ABOUT THE STATUS OF YOUR APPLICATION. VERIFICATION
WILL BE ENTERTAINED AFTER DAYS FROM THE DATE OF RECEIPT. YOU MAY VERIFY THRU
SSS WEBSITE AT www.sss.gov.ph
RECEIVING BRANCH
SS NUMBER NAME OF MEMBER (Surname) (Given Name) (M.I.)
PART II
PREFERRED MODE OF PAYMENT NAME OF BANK/BRANCH BRSTN (For SSS Use Only)

Cash Card x ATM/Passbook BANK OF THE PHILIPPINE ISLANDS

BANK ADDRESS SAVINGS ACCOUNT NUMBER

BANGA, CITY OF MEYCAUAYAN, BULACAN 4 6 3 9 0 2 9 9 7 8

CERTIFICATION
I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT, AND IF
APPLICABLE, THAT:
1. The aforementioned children are under my care and custody;
2. I am competent to receive in behalf of the said children the amount due them as dependents;
3. I have not abandoned, neglected, refused to support said children, nor caused them to commit
offenses against the law;
4. None of the aforementioned children are married nor employed; and
5. I will immediately notify the SSS in case any of the above listed children die, marry or become
employed, or I get re-employed before the age of 65 or 60, if underground miner.

SIGNATURE OF MEMBER DATE

(If claimant cannot sign, fingerprints should be witnessed by two persons)

WITNESSES TO FINGERPRINTS
Please affix signature over printed name and indicate date

1.

Right Thumb Right Index

2.

CERTIFICATE OF SEPARATION FROM LAST EMPLOYER

EMPLOYER NUMBER NAME OF EMPLOYER

0 3 - 9 5 5 4 6 2 7 - 9 COLEGIO DE STO NINO MEYCAUAYAN CORPORATION

ADDRESS (Number, Street and Subdivision) (Barangay) (Town/District) (City/Province) POSTAL CODE
EMA TOWN CENTER, STO. NINO DUBD., CAMALIG CITY OF MEYCAUAYAN BULACAN 3 0 2 0

I certify that BENJAMIN M. MORONIA JR. was separated from our employ on APRIL 10, 2018..

SIGNATURE OVER PRINTED NAME OF EMPLOYER/ OFFICIAL DESIGNATION DATE

EMPLOYER’S AUTHORIZED REPRESENTATIVE

FOR SSS USE

FINDINGS: SCREENED BY: RECEIVED BY:
No other pending claim
Others (specify)

SIGNATURE OVER PRINTED NAME DATE SIGNATURE OVER PRINTED NAME DATE