Republic of the Philippines
SOCIAL SECURITY SYSTEM
MATERNITY NOTIFICATION
C= 01264 (12.2018
"THIS FORM MAY BE REPRODUCED AND Is NOT FOR SALE, THIS CAN ALSO BE DOWNLOADED THRU S85 WEBSITE AT warwass-90r
IPLERSE READ THE STRUCTIONS AND REMINDERS AT THE BACK BEFORE FILLING OUT THIS FORM PRINT ALL FORMATION IN CAPITAL LETTERS AND
USE BLACK INK OMY,
S
PARTI. TO BE FILLED OUT BY MEMBER
"A PERSONAL DATA,
FSSNOWaER [GOMWON REFERENCE NONGER ron [ATE OF BIRTH pacar) [TAX IDENTIFICATION NUMBER Am)
Llitt petit itt ited tt
1)
E Day ‘waar EOE a
OCA ADDRESS
ERATE THE TORT
TTT
FROTET
EP cooe
fae
FELEPHONE NOMER pre caz ST
Litiiiiit
JHOBILECELIPHONE NOMBER
tditiiit
[EWALADORESS
FOREIGN ADDRESS oraPmicamy
[GOUNTRY
par cone
Teatty tat
2. This my.
», Prior to this noiieation, have
EL CERTIFICATION
pregnancy and my expected dat of dover ison
delveryies and
rmiscarioge
«, The information provided in his form are tue and correct.
‘for May 26, 1997 upto present and
PRINTED RANE
Below are the witnesses to fingorprinting:
» :
‘PRINTED WANE
[ADDRESS & CONTACT NUMBER
2
PRINTED WANE
[ADDRESS & CONTACT NUMBER.
ee
‘SGRATORE
\¥ member cannt sign, afi fegerpints. Please read Instruction No. 4 ofthe fom,
SIGNATURE
TE
IE
DATE
RIGHT THUS
RIGHT INDEX
PART
"ALENPLOYER DATA,
=O BE FILLED OUT BY EMPLOYER (FOR EMPLOYED MEMBER)
ERBCOVER TO NONGER
Fiititilit
[FAKIOENTIIGATION NUMBER pr
pitiitittis
THRE OF ENPLOVER
Dieusness
1 Housenoss
[ENeCovER wae
EaBLOVER ROORESS
jap CODE
{J 4
TEPHONE NOMBER pesos Tovar
1 1
HAL ADDRESS
[NESTE Fornimene mre
CERTIFICATION
Teeriy fat
2, The above-named member notified us of her pregnancy and is expected to give bith on the dae stated above; and
', The information provided inthis form are ue and corect
PRINTED WARE.
‘SIGNATURE:
POSTON TE
DATE
PART ill- TO BE FILLED OUT BY SSS.
JREGENED AND PROCESSED BY
‘SNATORE OVER PRINTED NM
DATE
BRANCHELIGIBILITY RESULT
(For SSS Use Only)
INSTRUCTIONS
Fi out this frm in oe (1) copy
[Always indicate "NIA" or "Not Applicable” i the required data snot eppicable
‘Af ials on al aeraonsforasues in his form.
itmember cannot sign, winésses to fingerprinting shal be as follows:
Filed by member
eS aecring personnel who shal affxhister signature on the space provided and shall incicate employee number and branch on the
"address and Contact Number portons provided in Pat.
2 lovers representativelcom
No aeee ese: One (1) winess i te members represeralvelemploye/emplayer's reprecentavelcompany representative and the oer
see p tea be any person, Both shoul fx their signatures and indicate tei addresses and contact numbers on the portons provided in
Pants.
‘A member shall submit the Matority Notification (MIN), 2 follows:
"TYPE OF MEMBER. WHO WILL FILE, WHERE TOPE, ‘DEADLINE GF SUBMISSION
fa Employed Member —[ Employer [any oT te Towing:
la. Nearest SSS Branch Office
9 beelgrney atleast 60 days trom tho dat|
[b SEN incoding — ]- SE [Any of the folowing: Se ae aea
OFWINWS) 1 Mt Gncluting OFWNWS) fa. Nearest SSS Branch Offce pecan
Member Separated |! Member Separated fom |b. Thu SSS Website ee
from Employment |" Employment lc. Thru Set-Service Information Terminal (SSIT) o
"When fing for materiy benefit alach the duly received MN or "Matoriy Notifcaion Submission Confirmation” (i MN is fled tu the SSS
‘Website or thru SSIT) tothe Maternity Beneft Reimbursement Appication.
REMINDERS
eceip ot MN doesnot quaanie payment of matey bene. Payment of benefit shale based on exsing SSS poles and guteines
Rae eecpat i pai ony forthe Wt four () pregnancies incadng miscariage. The fh complete dlvery er miscarage shal no
Tonge Be pad even no avalmens were made on previous delivers or miscaages
ears should heve atest hee (2) posted meihycorrbons win te wave (12}month prod immediatly preceeing the semester of
Cotvendnicariagelprocaaure
Payment af matey bereft automaticaly dsqualfes the member Kom aveing of sickness bent forthe same period
Tr ecoojed hi amount othe maternity benef shal be advenced by the employer wii hy 20) caye fom the fing of matey fave
‘ppleaton