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Self-Declaration Form of Survivor Pensioner On Non-Remarriage/Non-Cohabitation

This document is a self-declaration form for a survivor pensioner to confirm their non-remarriage and non-cohabitation status on an annual basis. The pensioner provides their name, age, citizenship, residence address, and confirms they have not remarried or cohabited with another person since the death of their spouse. They acknowledge the consequences of a false declaration and their obligation to report any change in marital status or cohabitation.

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Camille Francisco
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1K views1 page

Self-Declaration Form of Survivor Pensioner On Non-Remarriage/Non-Cohabitation

This document is a self-declaration form for a survivor pensioner to confirm their non-remarriage and non-cohabitation status on an annual basis. The pensioner provides their name, age, citizenship, residence address, and confirms they have not remarried or cohabited with another person since the death of their spouse. They acknowledge the consequences of a false declaration and their obligation to report any change in marital status or cohabitation.

Uploaded by

Camille Francisco
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

SELF-DECLARATION FORM OF

SURVIVOR PENSIONER ON
PEN-01561 (09-2021) NON-REMARRIAGE/NON-COHABITATION
Annual Confirmation of Pensioners Program

I, __________________________________, _____ years old, __________, and with


(Name of Widow/Widower) (Age) (Citizenship)

residence address at ____________________________________________________


(Residence Address)

_________________________________________, do hereby declare that I have not


remarried, cohabitated with another person, or otherwise engaged in a common-law
relationship since the death of my spouse, ________________________________________
with SS Number __________________. (Name of Spouse)

(SS Number)

I understand that if said declaration as given by me is proven to be false, my


entitlement to the death benefit of my spouse from the Social Security System (SSS) shall
be automatically cancelled/stopped.

I also acknowledge that once I remarry, cohabit with any person, or engage in a
common-law relationship, I shall report the same to the SSS, and applicable SSS policy
shall be implemented.

I undertake to return to the SSS, without need of demand or judicial action, all undue
pension benefits that I may have received after my entitlement thereto has been cancelled
as stated above.

I further acknowledge that any misrepresentation, concealment and inaccurate or


untruthful statement on my part shall be a ground for criminal and civil action against me.

Signature over printed name of


Survivor Pensioner

Date

Note: Please accomplish in one (1) copy and attach it to the Annual Confirmation of Pensioners (Pensioner’s Reply).

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