Republic of the Philippines SOCIAL SECURITY SYSTEM UNIFIED MULTI-PURPOSE ID (UMID) 10C-01408 (05.2078) CARD APPLICATION [ “THis FORM NAY BE REPRODUCED AND IS NOT FOR SALE- THIS CAN ALSO BE DOWNLOADED THRU THE SSS WEBSITE AV wan7sss.gonah ISCERSE REND THE TIS AUCTIONS AT THE BACK BEFORE ACFOUTISHING THIS FORM PRINT ALL FORMATION IN CAPITAL LETTERS AND USE BLACK NRGNLY "TO BE FILLED OUT BY CARD APPLICANT SARD APPLICANT DATA [FEOF CHRO APRTCRTON IC iia evnouwent[) can repcacewent Creieconencrics cs Cl peninetctina «Anema eonmoarpricos 2] uno ca Ti epacorateDansoee Cart] anensnetelFacectinn C] anerananetaaenteae reser] ones Sno ICOMITON REFERENCE NUMER oo | SBRREGEIPT NUNBERTTRANSACTION REFERENCE NOMBE® pray Tae EEC OF ERT OXTEOF RTH MOTT [ACE OF BRT CREDA) ———PROTTEERTAET TTT er LL mae remaue FAITERS NAME aT FETE OTT ae OTTERS UAIDEN WAME CST RATET FRETS EET ET SENOGRAPIIC DATE OE ORS TET RE TED ROTTER SARE FRETS POSTAL CODE [COUNTRY CODE SVL STATUS IFEIGHT pcoscens WEIGHT prasoson —[TSTNGUSAING FEATURES ID snc Oi wwanco C1 woowe D awwucoononcen C] Lecaty seranaren OTHER CARD APPLICANT DATE SSR OTTO ERT AOS TARE YOU A PENSIONER? Th yes D1 No, rave yuries & ust or pension? CSTE NUMBER Dyes Ove TrOPTION FOR UMD CARD AS AVM CARD OR REGUCAR UMD GRAS. [Ey RECUR UMD GARD ET UMD GARD AS ATHTCARD TBAWCHANE) ECT 5, DECEASED MEMBER DATA (1 Card Applicants Surviving Spo [SS NOWDEFICRN OF DECEASED EVER Avi OF DECEASED VEMEER UTE Ser ‘S-CERTIFICATION, DATA PRIVACY CONSENT AND AUTHORIZATION 7 leony nat he nformaton provided ars hue and coe. 2, I nereby zone + the colectn, dae capture, storage, amelie matching andthe celeron of my preoal cata forthe goreratonlupdating of my CRN, cart raduton and delivery, ther ‘rocessing ard payment of my loans and SSS berets + Sharng ofthese cata uth SSS serves provers to cry athe purposes stated ebove; an 4 dspesl tis apsleaton the meaner consistent with he Dasa Privacy Ac ‘5, Tal ha at thee data shal beep confide by SS and is eros providers ad my bank 4 rer ie my consent to SSS to shar passat ats with hy Shosen bank orn gaeceton of bank ascunt number, resting of oan an benet proceso he account umber snd ajrentof si an and bent pocoeds Far this purpose, leorsb far he sharing of my Bank aceoun nari wi SSS, PRINTED WN SORTORE Dae ear eppican eanet in, afta trgerets ‘wterescs to tngeenng (To be accomalshos by SSS rceng personel FRNTED WE aaa RANCH AND DESIGNATION RIGHT THUM RIGHT INDEX Pe ____il§ PARTI 10 BE FILLED OUT BY SSS AND DATA CAPTURE OPERATOR — RECEVED TNO SCREENED OY DATACAPTURED BY ‘SGNATORE OVER PRINTED WANE TATE TE ‘SIGNATURE OVER PRINTED NAME SSS ERANCH TESGRATON DATES TME ACKNOWLEDGEMENT STUB hebaclrbedrer ORR CATIRED TY EEG DESSHATON DRESTMEINSTRUCTIONS 1, Filout his form in one (1) copy. 2. Erasuresialteatons are not encouraged. However, if necessary, such wil be limited up to two (2) erasureslaltorations only. Atways affix intials on all ferasuresfaterations of his form. 3, Place a checkmark on the applicable box. 4. Always indicate "NIA" or "Not Applicable’, the required data isnot applicable. 5, Indicate the home address lf permanent home address isin the province but working in Metro Mi provincial adress instead of the Metro Mania address. 1, Write the "HEIGHT" in centimeters and "WEIGHT" in klagrams. To.convert, 1 ft=30.48m Yin = 2.54 om 1b = 0.4896 kg 7. Limit the cistinguishing features to those that can be found on the face such as “mole under the right eye" and “mole or bith mark on the fet cheok/forchead’ 8. Always incicate the following mandatory information: County of place af bit, ifbom outside the Philpeines ‘Mobile number, i applied localy” + Emsil address, f applied abroad™ "if catd applicant cannot provide the required mobile numberfemail address, Incicate the card applicants immediate family members mobile rnumberiemail adress where SSS can communicate with the card applicant ‘8. Forall types of card replacement, pay the required fee at any SSS branch offcelaccrelied bankicolecting agent, Write the Special Bank Receipt (SBR)Receipt Number/Transaction Reference Number onthe feld provided and submit this form together withthe required documents and proof of payment tothe nearest SSS branch office 10, For card replacement due to unclaimed UMID cards beyond five (5) years, 2 replacement fee and biometric data re-captureis required ‘1, Submit this form tothe nearest SSS branch wih the folowing required documents (use the table Documentary Requirements Guide). DOCUMENTARY REQUIREMENTS GUIDE ila uring weekdays or working abroad, Indicate the IDENTIFICATION REQUIREMENTS [Present the original DOCUMENTARY REQUIREMENTS (Submit the original) JA. Primary 10 cardidocument fany one (1) ofthe following [A For card replacement due to amendment of data/authentcaing Ct. Unies Mut Purpose 1D Cara finger) [2 Social secunty Cars CZ Previusly issued SS aigitzed 1D or UMID card ofthe card 1D 3. Alien Cerificate of Resistraton applicant D4. Divers License 1D Proof of payment 5. Firearm Registration For card replacement ce to lost SS digized 1D or UMD Care 1G. License to Own and Possess Firearms 2 Duly notarzed Affidavit of Loss 7. ‘National Bureau of Investigation (NB! Clearance Bi Provi of payment 8. Passport [c. For card replacement custo non-receipt of UMID Card 18. Permitto Cary Firearms Outside of Residence 1D Dulyrotarzes Atidavit of Non-Recsipt of Card B10 Postal dentty Cara 1B Nates/Email rom Identity Management Department (IMO) that 11, Seafarers leantication & Record Book (Seaman's Book) the courier lostwas notable to deiver the UMID Card 22 Voters ip Gara 1 Proof of payment lB. Any two (2) other 1D cards{documents, both with signature [D, For card replacement due to damaged UMIO Card, UNHID Care 2s, and atleast one (1) with photo (in absence of a primary card), | ATM Card and other reason/s Please specity. 1 Proof af payment a 12, Observe proper atre when applying for a UMID cara BOs, DONT Colared shibiouse & encouraged | ~ Wearmg of the folowing Face and neck should be free from ‘For Male undersnini'sando" andlor earings ——_d._ Metal plorcing in ary part of the face bandage or accessories ', For Female - dangling or overstated earrings. Head gear Eyeglasses andlor colored contac lenses 4 Sunglasses ‘te Pugs UN) Cae Apleton Page 2 REMINDERS 1. Gard applicants who chose to enroll the UMID Gard as ATM card at point of card application shall claim the same at the specified bank's branch or kiosk win thity (30) days upon reesiptof SMS notification from SSS. 2, Far regular UMID Card, the default mode of issuance fs pick-up at the SSS branch office where card application was made. 3. UMID Cards for pick-up at SSS Offices where card agplication was fled, shal be claimed within sity (60) days from receipt of SMS notification from 88, Otherwise, unclaimed UMID Cares within the 60-deys claiming period shall be veriied tha IMD or SSS hotine. Unclaimed UMID Cards beyond five (5) years shall be shredded or destroyed 4, Ta verify the status of your UMID Card application, you may reach us at 920-6401 local 5714 or email at sss_id@sss.gov.ph 5. Card applicants shal be required to verfy the statusievalsilty of their UMID Cards if wih change of mobile number ater the card application was ‘made or non-receipt of SMS notification from SSS within thy (80) days from card application 6. Unsuccessfuly delivered UMID Cards (RTS) willbe sent tothe SSS branch office where biometric data capture was made.