Republic of the Philippines SOCIAL SECURITY SYSTEM FUNERAL CLAIM APPLICATION [EONNON REFERENCE NUMBER an) fiitiit Lil CO Fema C Male TTT vam FOUR TTRRROT STREET REY OBST CoRR [a COBE Clwitowes (71 epaty Separates Dotter es. inscate IPLACE OF DEATH oT RELATIONSHIP TO MEMEER [GOMMON REFERENCE NUMBER iran [Sex mae 0 Femae [DATE OF BIRTH amcor Ee RDORESS OTRAS SREETHTE) SSNS RT OSTATOCATT ERORCFATTT FROWEE, CORT [ZF CODE [TELEPHONE NUMBER aa cane Te vo] MOBILEICELLPHONE NUMBER Funeral Benefit. ©. CERTIFICATION. { cortity thatthe information provided in this form ar true and correct and that |have no prior or pending claim for [EMAIL ADDRESS PRINTED NAME OF CLAIMANT ‘SIGHATURE OF CLAIMANT DATE claimant cannt sign fx ingerprints (lease see Instructon no.) RECENT Below are the witness to fingerprinting: x40 PRINTED WANE SGNATORE DATE ‘ROGRESS E CONTACT NOMTER, PRINTED WANE SIGNATURE DATE ricuTTHums || RIGHT INDEX "RODRESS & CONTACT NOMEER ditional information about me oF the deceased member Is required, the SSS may reach the persons Below: [SS NO /GONMION REFERENCE NO. (ra) SOCIAL SECURITY SYSTEM FUNERAL CLAIM APPLICATION ACKNOWLEDGEMENT STUB NAME OF DECEASED MEMBER STINE [RECENEDEY TSOUTRECERFRNTEO WANE “POSTION ONE RTE =a [REMARKS~ TO BE FILLED OUT BY SSS [vee oF GLAM [FAX IDENTIFIGATION NUMBER OF THE CLAIMANT «ram Oss Oe is DECEASED MEMBER CURRENTLY REGEIVING PENSION? TYPE OF PENSIONS 1 Yes (Pis. check type of pensions) Two C1 Noknowledge Retirement TD cisavitty (1 Deatn IF RECEIVING SURVIVOR'S PENSION, INDICATE SS NO /GOMMON REFERENCE NO. iran) AND NAME OF MEMBER [ss No.Common Reference No, IName of Deceased Member (USTHANE) vFRsT aM) moovenaney UF) I RECEIVING PENSION AS GUARDIAN OF RETIREETDISABILITY/SURVIVOR PENSIONER, INDICATE SS NO.GONMON REFERENCE NO. fF sv) AND NAME Jor mewser [ss No Common Reference No. Name of Member cust ane) FrRsr NAN (moouenane) Gur) JRONGS No Pending claim [5] Deceased pensioner has over paid benefit in the amount of B (it wth overpayment, request fer to flout the "Authority {0 Deduct from Funeral Benefit) I) Employment History Validated 7 others (speci: RECEIVED & PROCESSED BY REVIEWED BY [APPROVED BY THOUTURE OVER PRATTED UE one TTERUTURE OVER PRNTED AME oe SOUTREOWAPRNTEDNE "ONE INSTRUCTIONS Fill out this form in one (1) copy. ‘Always indicate "NIA" or “Not Applicable’, ifthe required data is not applicable. ‘Affix your initials on al alterations/erasures in this frm. ‘Affix your signature and attach your recent (1 x 1) ID picture on the portions provided for in Part I. If claimant cannot sign, witnesses to fingerprinting shal be as follows: a £l mans + SSS receiving personnel who shall affix his/ner signature on the space provided and indicate employee number and branch on the "Address and Contact Number” portions provided in Part ILC b. Eiled by e + Two (2) witnesses. One (1) is the claimants representative and the other one (1) could be any person. Both should affix their signatures and indicate their addresses and contact numbers on the portions provided in Part 1-C. 6. Please refer to the attached “List of Documentary Requirements for Funeral Benefit Process” for the documentary requirements and identification cards/documents REMINDER Verification of status of claim may be made thru the SSS Website at www sss.gov ph or contact our Call Center at 920-8446 - 55 or 917-7777 WARNING ANY PERSON WHO MAKES ANY FALSE STATEMENT IN THIS APPLICATION OR SUBMITS ANY FALSIFIED DOCUMENT IN CONNECTION WITH THIS CLAIM SHALL BE LIABLE CRIMINALLY FOR FALSIFICATION OF PUBLIC DOCUMENTS (SECTION 28 OF R.A. 8282).