Auto Debit Arrangement Enrollment Form
Download a blank fillable Auto Debit Arrangement Enrollment Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Auto Debit Arrangement Enrollment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Auto-Debit Arrangement
SSS FORMBmbr-119(1/94)
Accomplish in three (3) copies.
EFFECTIVITY DATE:
___________________
SS Number
Surname
First Name
Middle Name
NAME OF QUALIFIED SSS MEMBER
ADDRESS
DATE OF BIRTH (mm dd yy)
TELEPHONE NUMBER
Zip Code
Account Type
BANK NAME
BANK BRANCH
Bank Account Number
Current
Savings
MEMBERSHIP & TRANSACTION TYPE
Amount
1. CONTRIBUTION
[ ]
SELF-EMPLOYED
[ ]
OTHERS: (Specify) _________________________________
[ ]
OVERSEAS FILIPINO WORKER: COUNTRY CODE:__________
P
[ ]
VOLUNTARY MEMBER
2. HOUSING LOAN
Real Estate Loan Acct. No.:
P
Loan Date
Date to End Deduction
Loan Type
Monthly Amort.
(mmddyy)
(mmddyy)
No.
Salary Loan
1
Educational Loan (SNPL)
2
Emergency Loan
3
3. LOAN
Calamity Loan
4
Stock Investment Loan
5
Others (Specify)
6
Total
P
4. HOUSEHOLD EMPLOYER
(Attach additional sheet if necessary)
Date of
Loan
Monthly Loan
Monthly
Employee Name
SS Number
Birth
Date/Type
Amortization
Total
Contribution
(Surname, Given Name, Middle Initial)
(mmddyy)
(mmddyy)
(I+II)
(I)
(II)
P
Total
GRAND TOTAL (1+2+3+4)
P
I hereby authorize the above stated bank to automatically deduct from my account the grand total amount of _____________________________
__________________________________________ (P ___________________) due me and to remit the same to SSS monthly.
It is hereby understood that the information contained herewith shall remain in force until the necessary corrections/changes
are made in writing and I hereby agree to be bound by the terms and conditions printed in the reverse hereof or any amendment thereto.
_______________
________________________________________ Conforme:___________________________________
Date
Qualified Member’s Signature
Signature of Account Owner
(if other than Qualified Member)
FOR BANK USE ONLY
FOR SSS USE ONLY
Received/Verified by:
Received/Verified by:
Date
Date
Encoded by:
Acct. No. & Signature Verified by:
Date
Date
Approved by:
Approved by:
Date
Date
Internet Edition (1/2014)
PLEASE READ TERMS AND CONDITIONS ON PAGE 2 OF THIS FORM
PDF compression, OCR, web optimization using a watermarked evaluation copy of CVISION PDFCompressor
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business