Republic of the Philippines Wu SOCIAL SECURITY SYSTEM VA SSS P.E.S.O. FUND \eenrenaoin, RETIREMENT BENEFIT CLAIM FORM TS FORD WAY BE REPRODUCED AND 8 NOT FOR SALE, THs CAN ALSO GE DOWNLOADED AT THE 688 WEBSTTE AT wre gme ph B 7 Ti T TTA RSTRNT TIESTENTE [emt STATUS mee Creme |Usingie Cimarica Owieowed CD togaty separated Dotrere IDORESS IN THE PHILPPINES TARANT NORRIS WHET FOERGT BIR NOT STREETS) SRST ERNST TREREPATTT PRONE FOREIGN ADDRESS (F APPLIGABLEY [COUNTRY [TEL NOvaREACODE=TEL NO) ] MOBILEIGELLPHONE NUMGER EMA. ADDRES MEMBERSHIP TYPE Dl empioyea 1D serempioyed D1 vountary i nonvorting Spouse __[2) Overseas Fano Worker (OFW) [BANK RAMEIBRANCH BANK ACCOUNT NO, BENEFIT PAYMENT OPTION [GHOOSE ONLY ONE (7) OF THE FOLLOWING wwe sum OC PeNsion (D LumPSUM AND PENSION No.of Monthy Pensions Lump-sum Amount No. of Monty Pensions: C. BENEFIT CLAIM THROUGH REPRESENTATIVE 1D. CERTIFICATION. | cert thatthe information provid in this form are true and correct. i member cannet sign afc {ingerpns in the presence ofan SSS authorized offcor) RIGHT THUMB RIGHT INDEX SIGNATURE OF MEMBER PART Il TO BE FILLED OUT BY $35 "A BENEFIT CLAIM INFORMATION "ACCOUNT SUMMARY ONTRIBUTIONS 1D oisaPPRoveo 2 Fdings ondentfeaton documents: 1 Ne SSS Retcement Claim Fes ‘SIGNATURE OVER PRINTED NAME Wim settes SPF Retirement Claim otras DATES THETESTRUGTIONS Fillout this form in one (1) copy without erasutes and alteration. Submit his form fo the nearest SSS branch ofe. Review and confirm the information in the accomplished and prntec form provded by the SSS authorized officer by personally affixing signature or thumbmark (unable to sign) in the presence of an SSS authorized ofcer. Retirement beneft amount shall be credited fo the SPF Member’ enrolled bank aocount in three (3) working days from date of epproval,