Republic Of The Philippines Social Security System Retirement Claim Application
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2
3Republic 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
(
)
ADDRESS
POSTAL CODE
(Number, Street and Subdivision)
(Barangay)
(Town/District)
(City/Province)
DATE OF BIRTH
PLACE OF BIRTH
GENDER
(mm-dd-yyyy)
(Town/District) (City/Province)
Male
Female
CIVIL STATUS
TIN
TELEPHONE
MOBILE NO.
(Including Area Code) /
Single
Legally Separated
Married
Widow/Widower
EMPLOYMENT HISTORY
(Use separate sheet, if necessary)
PERIOD OF EMPLOYMENT (mm-yyyy)
NAME OF EMPLOYER
ADDRESS
From
To
1.
2.
3.
4.
DEPENDENT CHILDREN
(Below 21 years old or above 21 but incapacitated)
CHECK APPLICABLE
DATE OF BIRTH
COLUMN
ADDRESS
NAME OF CHILDREN
(mm-dd-yyyy)
Legitimate
Illegitimate
1.
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
?
Disability
Death
Yes
No
Yes
No
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
SIGNATURE OVER PRINTED NAME
DATE
(04-2012)
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
RECEIVING BRANCH
SS NUMBER
NAME OF MEMBER
(Surname)
(Given Name)
(M.I.)
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