Republic of the Philippines

SOCIAL SECURITY SYSTEM

_______________________________

( Branch Name)
____________________________________
(Address)

(10-2008)

(Name of Claimant)

(SS No.)

(Address)

(Name of Member)

Checklist for Retirement Claim Benefit

(

) Retirement Claim Application (RCA) Form

) Certification of Separation from the last employer, if certification portion of the

RCA was not accomplished by last employer

) Certification of non-renewal of professional license/business permit from

applicable offices for member less than 65 years old (e.g., Business Permit and
Licensing Office, Professional Regulations Commission etc.) or certificate of
cessation of business issued by the barangay of your locality and affidavit of
cessation of business/practice of profession.

) Certification from the company that you are an underground mineworker indicating
the period of employment and supported by your job description.

) Affidavit of no earnings from self-employment for member less than 65 years old,
accompanied by a certification of cessation of business issued by the barangay of
your locality.

) Marriage Contract

) Birth/Baptismal Certificate of dependent children

) Proof of relationship with SSS member such as record of birth, a statement before
a court of record or any document acknowledging the relationship, for illegitimate
minor children

) Medical Certificate of incapacitated member issued by the attending physician

) Medical Certificate of incapacitated child issued by the attending physician

) Application for Guardianship (SS Form CLD-15)

) Guarantors Form (SS Form BPN-107)

Affidavit of Separation (SS Form E-417), in the absence of employer's certification

of separation (if last employer no longer exist/if member's residence is far from the
address of the last employer within/outside the Philippines)

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Checklist for Retirement Claim Benefit

(

) Affidavit of Guardianship (SS Form CLD-1.1B)

) Joint affidavit of two (2) disinterested persons attesting to the fact, if such is
the case, that _____________________ and _________________________ are
one and the same person, stating therein the correct name.

) Latest 1 x 1 picture of claimant

) Original and photo copy of claimant's Social Security Card, Passport, PRC Card,
Seaman's Book, Driver's License or any two valid Ids, at least one with photo(e.g.,
Company ID, Senior Citizen's ID, Police or NBI Clearance, Voter's ID etc.)

) Others _________________________________________________________________

Passbook/ATM card with name or copy of validated deposit slip (original and
photocopy) or Cash Card Enrollment Form, if pension
_______________________________________________________________________

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

FOR SSS USE

SCREENED BY:

SIGNATURE OVER PRINTED NAME

SC01

DATE

SCREENED BY:

SIGNATURE OVER PRINTED NAME

SIGNATURE OVER PRINTED NAME

SC03

DATE

SCREENED BY:

SCREENED BY:

SIGNATURE OVER PRINTED NAME

SC02

DATE

SC04

DATE

NOTE:
1. Birth certificate and marriage contract should be duly registered with the National Statistics Office/Local Civil
Registrar Office and baptismal certificate by the Parish/Church.
2. In refiling, please attach this letter to the retirement claim application.