Social Security System Death Claim Application (Page 2 of 3) in pdf

Social Security System Death Claim Application Page 2

INSTRUCTIONS

1. Accomplish Parts I and II of this form in one (1) copy without erasures or alterations.

2. Support date of birth, marriage or death with birth/baptismal certificate, marriage contract or death

certificate (original duplicate/certified true copy/certified photocopy) duly registered with the National

Statistics Office/ Local Civil Registrar Office/Parish/Church. The baptismal certificate may be submitted in

lieu of birth certificate. For member who died abroad, death certificate should be duly registered with the

Vital Statistics Office of the country where the member died.

3. Present original and submit photocopy of single savings account passbook/ATM card with name and

copy of bank validated deposit slip or Cash Card Enrollment Form.

4. Attach your recent 1 x 1 photo.

5. Affix your fingerprints (right thumb and right index) on the portions provided for in the application form in

the presence of an SSS employee. In case the claimant could not sign, fingerprints should be witnessed

by two (2) persons, at least one (1) of whom is an SSS employee.

6. Present Social Security Card or SS Form E-6 Acknowledgment Stub with 2 valid IDs, at least one (1) with

photo.

7. Present original and submit photocopy of identification cards.

Write "N/A" for items not applicable and/or delete portion/s not applicable in the Certification

W A R N I N G

ANY PERSON WHO MAKES ANY FALSE STATEMENT IN THIS APPLICATION OR

SUBMITS ANY FALSIFIED DOCUMENT IN CONNECTION WITH THIS CLAIM SHALL BE

LIABLE CRIMINALLY FOR FALSIFICATION OF PUBLIC DOCUMENTS (SECTION 28 OF

R.A. 8282)

N O T E S :

1. RE-COMPUTATION OR ADJUSTMENT AND FILING OF PETITION ASSAILING SETTLED

CLAIMS SHALL NOT BE ALLOWED AFTER TEN (10) YEARS FROM THE DATE OF INITIAL

SETTLEMENT OF CLAIM.

2. A PERSON WHO CONTINUOUSLY RECEIVES MONTHLY PENSION DESPITE OF RE-

MARRIAGE OR COHABITATION SHALL BE CRIMINALLY LIABLE UNDER RA 8282 (Social

Security Act of 1997).

Social Security System Death Claim Application Page 2