ublic of the Phillppine0s

sOCIAL SECURITY SYSTEM

MATERNITY NOTIFICATION
SIC-0124
T ro AY BE REPROOUOED A NOT rOR ALL THe GAN ALSO BI DOWLOApe TU Be AT
IN CAPITAL LETTERS ANO
EASE REA0 THE INSTRUCTONS AND REMNOERS AT THE BACK DEFÖRE FILUING OUT THES FOM PRNT ALL NOMATIÖN
SEAINKONLY PARTI-TO BE PILLED OUT SY MEMBER
APL
PERBONAL OATA
SMU
ABER N REFERENCE NUMBER pAMm DATE OF BDc TAK DENTFCATION NUAER
NAME LILLLLL
LOCAL ADORESS
ARANATE TAKTZBAUm ROWHCE 2IP CODE

TELEPHONE NUMBER OBLECELLPHONE MUASER

EML ADDRE SS
ZIP CODE
FoRERON ADORESS C coUNTRY

.CERTIFICATOM
I certty th
is on

isy- gnancyd my epecied dae of deivery

* nd cnbgen
1rom May 24, 1997
up to present; and
The infomastion provided in tia form arn trus and comed

PRINTED NAME SIGNATURE DATE

miruction No. 4 ohe m
e e r carmo ign. ai neprints.Fessersad

RGNATURL

ADORESS&cONTACT MUMBER
SIGNATURE DATE RGHT TH
WHENTLO
ADORESS &CoNTACT NUNMER
PART I -TO DE FLLED OUT Y ELOYE (FOR LAPLOYED E
AEPLOYVER OATA
EMPLOYER MMEA P E OF BMPLOER
TAX IDENTRCATION NMBER #*

EMFLOVER ADORESS
dwAHACTAOEALUT HOVL

L
ELEPHÖN NUMBER coo E MAL ADORES5 WEBSITE POn Nenda novtk

cERIRATO
ICetaly hat
n e B0ove-niameu memoer nomeO ue or n o p e g n a n o y n o s exKpeclea lo o v e Dirn 0n i e oBte Suled abOVe, and

The informalion provided In this form are inue and comec

RNTEDNE POSION UnE DATE

PART II-TO BE PILLED OUT DY s38
RECENED AND PROCESSED BY

GNATURE OVER PRINTED NAME DATE TME BHANCH

 FLIGIBILITY RESULT

INSTRUCTION
a e A or No Appllcable", Wthe required data ls nol uppcabe.
Atx nals on aillero
lo tngeprnling shel be as lohows
member cannol sign. wibnds ses
SSS recelving personnel who shel at hinher signakure on he space provided and ahel inokcale empioyes nmbe ma o
NuoPponons provoed
m Pt 8.
C
0
atnelemaeY reoreMntait
-Two (2) wernesses. One (1) winess s tha members ropresentatvelemployerlemployern representalive/company representee and the oe
Part - 8 .

YPE OF MEMBER WHO WILL FILE NE S DEADLINE OF SUBMSSION

Employe o
Empioyer Any of thelolow

b. Thru $sS Webaite

SEMoncluding han the dele of
OFWW ncong WwS
Memt
from Employment Employment C. Thu S e S e c e inomabon leGmna (ss

NDER
longer be paid even I no avainents were made on previous deiveryes or miscamieges.
posed moriy coriribuibons weinin he w e e (7-monih pernod mmeaaieY preceg emesier o
eber ahove ee )
megeroc
ant of maternity benell automalilcaly dsqailes the member trom avaling of sictress benet for the same pernod
5. employed, hul amount ol he malernay bernelit shal be advanced by he employer w n t y (0) days rom he fing of maleimny heve
pplcabon
MONTHLY cONTRIBUTIONS SEVM CONTRIBUTIONS FLEXI-FUND WISP

MONTHLY CcONTRIBUTIONS

Year Jan Feb Mar Apr lay Jun Jul Aug Sep Oct Nov Dec

2022 0.00 910.00 1820.00 1755.00 1625.00 910.00 0.00 0.00 0.00 0.00 0.00 0.00
2021 1625.00 1170.00 1430.00 1170.00 300.00 1365.00 1170.00 1170.00 975.00 520.00 1495.00 910.00
2020 1680.0 1200.00 0.00 0.00 0.00 0.00 0.00 0.00 720.00 1080.00 1320.00 900.00
2019 1210.00 1045.00 990.00 1140.00 1080.00 .00 1080.00 1200.00 960.00 1020.00 900.00 0.00
2018 660.00 660.0 660.00 715.00 0.00 0.00 0.00 0.00 0.00 935.00 1375.00 1265.00

SUMMARY
(A) Total Number of Cotributions Displayed
(B) Total Number of Contributions not Displayed
Total
Number of Contributions Posted (A)+ ) 41

Total Amount of Contributions 45,895.00