Republic of the Philippines p WY SOCIAL SECURITY SYSTEM <4 ANNUAL CONFIRMATION OF PENSIONERS PEN-01406 (04.2019) PENSIONER'S REPLY THIS FORM WAY BE REPRODUCED AND IS NOT FOR SALE. THIS GAN ALSO BE DOWNLOADED THRU THE SSS WEBSITE AT wwrwats gov PLEASE READ THE ATTAGHED INSTRUCTIONS BEFORE FLUNG OUT THIS FORM PRINT ALL INFORMATION IN GAPITAL LETTERS AND USE BLACK INK ony, PARTI. TO BE FILLED OUT BY PENSIONERIGUARDIAN, YEE OF PENSION CURETIREMENT __C]SSPERMANENTTOTALDISABILITY _[]EC PERMANENT TOTAL DISABLITY __[JSSDEATH__CJEC DEATH. 7A DECEASED NENBER DATA (FOR DEATH PENSIONER SSNOMGER mi TET mE EET SE PENSIONER DATA [CONMION REFERENCE Lit TST, OTHERS WOAIDEN NAME CSTR RST TET SOLE NAY war LOCAL ADDRESS FRETS ERE TTT FORE TOF TSTREETAET ERR ESTRET CAT TEI ANEPRITT FRO POSTAL CODE} IMOBLEXCELLPHONE NONGER EAC ADORESS etna Sapandent minarcapastatoa) cHIa UNG Your cae and CusGay ready Maried, SlO/ Aaa ployeG or Goceasee? Z Yes (il out tne appicabe data wit ihe format aMDO-YYYY) C1] No DATE OF EWPLOVAENT? ‘SS NUMBER SELF-EMPLOYMENT __|(F EMPLOYEDISELF-EMPLOYED) DATE OF MARRIAGE, DATE OF DEATH D_GUESTIONNARE For retiree (aaiding abroaay pormanont otal aabillypanslover, have you been rear playeaosuTed car aT Oy C1 Yee, incicate ne folowing Om DATE OF RE-ENPLOYWENT NAME OF EMPLOYERIBUSINESS ‘ADORESS OF EMPLOYERIBUSINESS | UATE OF REEMMLOTMENT 2, For survivor pensioner, have you been e-mariedc curenty cohabiting wih anther person? D1 Yes, incicat the folowing On [NAME OF SPOUSE/PARTNER DDATE OF RE-MARRIAGE/COHABITATION 4. For rote (elding abroadpermanent oa ia andasiod”? (Yes Filcut he apical data below Om TAME OF DEPENDENT Genoumcn] DATEOF | DATE OF EMPLOVIENTT | —DATEOF (WaNORINCAPACITATED) CHLOIREN mareisce | SELFENPLOYMENT | DEATH itylsurvivor ponsloner, Ware thre any depancent(rinarincapactatad) chien under your care Tsp othe Pupp. V4 SOCIAL SECURITY SYSTEM 4 ANNUAL CONFIRMATION OF PENSIONERS ACKNOWLEDGEMENT STUB & NOTICE OF SCHEDULE eee en ae) RET LET a Littitt Please report for your Annual Confirmation on ‘Otherwise, your pension will automatically be suspended |ssucosy JGHATURE OVER PRINTED NAME POSTONTTE DAE THETE GERTIFIOATION AND DATA PRIVACY NOTICE & AGREEMENT | cert that the information provide in ths form ae true and cote. | agree that te nformation collected through tis frm shal be used and retained by the SSS or the processing and continuous payment of penien, forthe establishment, exercise or defense of SSS' legal claims and reestablish or continue the operations ofthe SSS inthe event of aster. may get a copy of this frm and coract or revge any information therein, Furthermore, | understand that |, a8 an SSS pensioner, shal be subject to other verification processes as required by the SSS fo ensure my eit to receive the SSS pension benef thatthe result ofthe verification processes shall requ me to appear personally to any SSS branch, Proved, further, that ‘SSS shall conduct a home visti fall to report upon the request of SSS. ‘PRINTED NANE OF PENSIONERIGUARDIAN ‘SIGNATURE DATE "1 pensioneriguarian cannot sign atx ngerprnis, Witness to figerpinting [To be accomplished by SSS persennelbark recaving personnevauronzes representatve (tied tru representative) PRINTED NAME ‘SGNATURE POSITIONRELATIONSHIP |SSS BRANCHIBANK BRANCH/AUTHORIZED REPRESENTATIVES ADDRESS RIGHT THUNB RIGHT INDEX PARTI TO BE FILLED OUT BY THE BANK MANAGER (FOR RETIREE RESIDING ABROAD AND DEATH PENSIONERS COMPLYING WITH ACOP THRU THE BANK) EES EEE ESSE EE ‘This st cert that MMs, 8 depostor of. (ean Bune personaly appeared before the undersigned on, ‘2 complance win the Annual Confimaion of Pensioners Program (ACOP) being conducted by he SSS. SOTA, FOSTONTTE DAE ETE CoM Caren CTR RePReSenTATWE Sa Cem TT ey oper eoatited TI BecenadPensrer 1D For data capture Date of Death 1 For further interview ITER ENED BROOH SCREENED EY FERED NE SORT FOSTONTTE ORE RTE LJ Continue To Pending (For further evaluation) CO suspend (Reason) D X-raylECG for reading Co Cancel (Reason) For Medical Fieldwork Services/Fact of Pensioner’s Existence 1C Re-adjudicate (Reason) 1 For referral to other Branch/Unit 1 Return ACOP form (Reason) CO Others (Reason) RE TEWED AND REOUNENDED AT PRINTED RANE ‘SIGRATURE POSTON TLE DATE BTIME PPROVEDBY PRINTED NAME ‘SIGHATURE POSTION TLE DATE ATE WARNING ANY PERSON WHO MAKES ANY FALSE STATEMENT IN THIS FORM OR SUBMITS ANY FALSIFIED DOCUMENT IN CONNECTION WITH THIS FORM SHALL BE CRIMINALLY LIABLE UNDER SECTION 28 OF R.A. 1161, AS AMENDED BY R.A. 11199 AND ARTICLE 207 CHAPTER IX OF P.D. NO. 626 “anal Cartrmatono Parone Fan (Ponaorers Rep) Pape?INSTRUCTIONS Al retiees (residing abroad), permanent total cisabity pensioners, suvvor pensioners, dependent (minorincapactated) chien and their guarian shall be required to repr forthe Annual Confirmation of Pensioners Program (ACOP), 98 flows: “Type of Pensioner ‘Schedule of Compliance Whare to Comply ives (esting abroach Nfoth of bith of te pensioner |» Member Serazs Secon of any SSS brancivsarviceoregn Oca OF + Depository bank Permanent Taal Daabiiy Kionh of bith of he pensioner |e Medical Evaluation Sean of any SSS branch ofice [Survvor Ionihof bith of the deceasea]e Member Services Secon of any SSS brancivserviceToreign ofice Ot member J+ Depository bank [Dependant winorincapactated) wit|htorsh_of bith of Whe membe|e Member Services Secon ofany SSS brancvserviceToreign Office: or [ne guarcian deceased member > Depostry bank Fi ut tis frm inane (7) copy. If recaving two 2) or more iypes of pension ll out one (1) ACOP form for each type of pension. (e.g Ifthe pensioners receiving both retrement and surviver pensions, the pensioner shal fl out two (2) ACOP forms). if guardian of two (2) or more dependent (ranerincapactated) children, fi out ono (1) ACOP fom foreach dependent (rinorincapactated) chia Alvays aff inls on all erasures/aertions on this fom. Aways indicate te folowing mandatory information: + PensioneriGuardans date of birt + MobileiCeliphone rumbert * if pensioneriguardian cannot provide the requied contact information, indicate the pensioners immediate family members contact information ‘where SSS can communicate with the pensioner. + Email addeess (or pensioners residing abroad) Aways indicate "WA" or “Not Applicable’ he required daa isnot appicable, ‘Write “Nothing Follows” immociatey afer the last dependent (minodincapacate) child, (tem Part -D Table) Submit his for together wit the folewing identification documents and documentary requirements based on the checks below T CHECKLIST FOR IDENTIFICATION REQUIREMENTS TYPE OF FILER "AUTHORIZED (SSS/Bank receving persoone to check the appropriate box ofeach ID submitediprsented and] PENSIONER. REPRESENTATIVE write any remarks, necessary) (Present origina) (Present original and _submit photocopy) “A Primary Ib eardldocument (Any one (1) ofthe following): 1 Unied Mut-Purpose ID Card o o 2. Sodal Secu Cara o o 3. Alien Cerificate of Registration o o 4. Diver's License o o 5. Frearm Registration o o 8. License to Own and Possess Firearms o o 7. Natonal Bureau of Investigation (NB!) Clearance o o 8. Passpot o o 8. Permit to Cary Firearms Outside of Residence o o 10, Postal dentty Card o o 11, Seafarers lentfcation & Record Book (Seaman's Book) o o 12, Voters 10 Cars a o Any two (2} other 1D eardsidocuments, both with signature and atleast one (1) with] o o ‘photo In absence ofa primary ID card/document), Please specify. . Leter of AuthortyiSpecial Power of Attorney o a ~____ EF GHECKLIST FOR DOCUMENTARY REQUIREMENTS. ‘A. For pensioners residing in the Philipines (if unable to report personally, submit original copy ofthe following documents: 4. Permanent Tota Disabilty Pensioner ‘eonfined at home sketch of residence of pensioner f uti 1D Coricaton from the insttuion where the pensioner is confined suchas etiement home, penitentiary, nursing facty, hospital, corectional Inatittion rehabitation center tc 2. Survivor Pensioner and Dopendent (Minorincapacitated) Children ‘Leonfined atome Tr stoten of residence of ponsioner; i Corticaton of pensioner’ existonce from Barangay Chairman; and 1B Medica certicate on examination done wih tree (3) months of date of complance and coriied by @ physician indicating his teense umber and cinic adress. (9. If pensoner complied in une, medical certificate on examination done should be within Api, May and ‘confined in an intition 1D Corttication trom the insttuton where the pensaneris connod such as retrement home, penitentiary, pursing fait, hospital, corectionl Instron, renabtation center, etc. ote. ‘Submission thru mail (ghotocopy of identification requirements and orginal copy of documentary requirements) shall be adoressed tothe branch head of any SSS branch ofce. 1. For pensioners residing abroad, submit original copy of the following documor 41. Total Permanent Disability Pensioner G1 Complete phyeical examination report done within three (3) months of date of compliance ‘umber and cine adaress (eg I pensioner comped in June, medical certifiate on sone); and 1D Laboratory or other diagnostics examination resus appicable to disabity 2. Retire, Survivor Pensioner and Dependent (Minorincapacitated) Children ted by a physician indicating his toons tion done shoul be within Ape, May and ‘confine in aninstituten D Corticaton tram the institution where the pensioner is confined suchas retirement home, penitentiary nursing fect, hospital, corectional Insttution, ronabitatio canter, tc. te ‘Submission tru mail shall bo sant to OFW:Contact Services Secton, International Operations Group, 2nd Fleer, SSS Main Ofice, East ‘Avenue, Diiman, Quezon Cy, Philppnes 1100 er emal a ofv-reations@Sss gov Ph “Tana Cantata a Prana Fa Pansare?s Papi) Pages