Republic of the Philippines Wa SOCIAL SECURITY SYSTEM REQUEST/VERIFICATION FORM AMEN! TONER ISORNTON REFERENCE NOMBER DATE GF RTH mnorr7y TONER To fede ia indie OT fe Tt Pf pp ee pak ste amber cor Lahr TOCAC REDRESS RTA RETR aT FORTETEBICET eran —] ST RT TT OE, CORE HECEPRONE WOMBER oaorcoava va) |WOBICEICELLPHONE NUMBER [EWA ADDRESS [GENER Fae TR WT aa aan Owe 0 remue FOREIGN AGORESS ramos [COUNTRY jarcooe [TYPES MENBERSHP Gi eworoveo Cl vowntary DO) SEiF-ewpLove D1 NON.WORKING SPOUSE _] OVERSEAS FILIPINO WORKER, ore Zi Canceation of Mutipe SS Numbers, insicat the following informaton: ‘vi Status Name of Spouse Maiden Name itera Name of hiciChicron —T Nome of Father 2 Name fMther 3 Di Consolidation of Contibutons former se male anaara) 1D Deletion ot Enty in Empioyment Psion Record Gi ComrectontetundPosing/Adiustment of Cntnautons D ErcosinglCorecon of Date of Coverage 1D Manuat Veriicaton Employment History (Tobe fllec-cut by member requesting for te above request) - Pease use separate sheet i necessary NAME OF EMPLOYER "ADDRESS ree eT dh PEO ee b Poh ae (Di Coniteaton of erbachenon Nonberrip TL Pra ot Computer Reco San nrcicw hon Paencruheo fa Pam 1B copy of Membership Recor {SSHPESG findPenumiErlome Naya orton Teme OD oners [Cr VeRIFIcaTioW Er Contribution ruse reuse 1D Loonsibenetis tgiby 1D Detect Coverane 1B siaus of Gl Eneioyer Nunber Leen Application 1 sstunver D Benents Clim Applicaton stinumsonsyecstiyetenevinttewnt Ey FleciFund Premiums 1B Aonticaton er uo cara Gl ssp s 0Fune Premiums Data cnarge Requestes cami Tautnorize MMs. To requestveriy the information requested above andor sgn ‘documents necessary for the release ofthe result of te said request/verifcation. PERTED WARE SGRATURE OF AUTHORED PRERTES NATE E SORATORE OF EOE [Petrone tr weave ctreqeavericaton SY Gi Formating C) ForPickup irscun ane on Taanttcaton documents resoned by Neva TarNed BUM aTESTCD OHESOTAIWS oss D1 Two 2) valid 1s Tore se ire SOCIAL SECURITY SYSTEM REQUESTIVERIFICATION FORM ACKNOWLEDGEMENT STUB. PS RMBENCOWON RETEST ERR ONE TATE FETT TOE a JRECENED BY SIGNATURE OVER PRRTED RATET TRANSACTION RESOLTS [5 Cancettion of Mate SS Numbers D1 De%etion of Entry n Employment History Recore TD Consotdation of Conreaions| Cr EneosingtCorecion of Dale of Coverage 5 correctonRetundPostingiAcjstment of Contributions D taanual Veriication | Certicaton of tenbershipNlon Membership 1 Pantoutot Computer Recors Di copy ot Membersnip Recorars oners 1D Loon Balance C LoenerenettsEngiity Ci siatus of 1G Loan Application 1B Benetts claim Agpication, Di Application for ump Card, 1 bata change Requested Doves SSS PESO Fund Premuims TO BE FILLED OUT BY DEPARTMENTIBRANCH CONCERNED. SIGNATURE OVERPRINTED NANE_“DEPTIBRANGH ‘DATES TIME | SIGNATURE OVERPRINTEDNANE _‘DEPTVGRANGH DATE A TIME INSTRUCTIONS 1. Fillo tis fom in one (1) copy and accomlish aperopite parts 3 follows: Fle by menter Member to i-out PART Ia to ¢) + Member to fi-out"Employment History (Par |b) only requesting forthe flowing CCancelation of Mutiple SS Number Consolidation of Conrbutons - Correctio/ReundPosting/Adustment of Contibuions ‘Deletion of Entry in Employment History Record Encoding/Corecton of Date of Coverage Menus Verification Fle. authorized representative oc company eptesentaive ‘Member to f-out PART I (ato 6) + Ahorzed Represeniatve ox company repesentave to fillout PART () Place a checkmark onthe appicable box ‘Always Inseate "NIA" "NOt Applcable’ the equred datas not applicable Present enifation documents ‘Fes mesbee + Social Secury (SS) Card o Unified Mult- Purpose IO (UMID) Card or Passport ox Professional Reguation Commission (PRC) Card or Seaman's Book or Driver's Llcanse or wo (2) va IDs (bth wih signature and atleast one (1) with phot) Fed. authrized reoresetative. Representatives SS Cara or UMD Card or Pasapor or PRC Card ox Seaman's Book of Driver's License or any two (2) valid IDs (both wih signsture and at east ‘one (7) with photo) + Members SS Card or UMID Card or Passport or PRC Card or Seaman's Book cr Drive’ License or any two (2) valid IDs (bot wt signature anda east one (1) wath ao) Fl by company repesentative + Aulhrzed Representative Card (ACR) Orginal member SS Card or UMD Card or Passport or PRC Card or Seaman's Book or Driver's License or any two (2) vals IDs oth wih signature and at east ene (1) win prot) 5. The member granting authorly to he aubwoized representative or company representative in tis form shall be hed able under al crcumstances for any fase statement, mereccenertalon aud made bythe authorized rexeseriave or company representative in al ransactions wit the SSS, 18 This form can be downloaded thr the SSS Website at www S85 go. 20