Republic of the Philippines 9 SOCIAL SECURITY SYSTEM SSS P.E.S.O. FUND ver-or2se (02207) + TOTAL DISABILITY BENEFIT CLAIM FORM "THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE. THIS CAN ALSO BE DOWNLOADED AT THE SSS WEBSITE AT wwrw-sss.g0v.ph. PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT THIS FORM PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK INK ONLY. TO BE FILLED OUT BY THE MEMBER "PERSONAL DATA [COMMON REFERENCE NUMBER DATE GF BRTH GunvOONT) | TAR TDENTIFICATION Loitip ei i tii titi ii tit STANT FRSTTATES COTE NEY SFR ENDER [evi STATUS wale Chremaie [CI single CD warree Cweowes C1 Legaly Separates Dorers. ADDRESS IN THE PHILPPINES TRIFIRARTT HO TRS WAT TOELOT EER NOT STREET ET EGET ORATOR OAT TRING PROC, FOREIGN ADDRESS (APPLICABLE) [COUNTRY TEL NOL (ARER CODE TEL NO} | WOBILEICELLPHONE NUMBER, EMAIL ADDRESS FERGERSAP TYPE DC empioyed DO seitEmpioyed Voluntary TF Non-Working Spouse TZ overseas Filipino Worker (OFW) [BANK NAMETBRANCH [BANK ACCOUNT NO, BENEFIT PAYMENT OPTION. HOOSE ONLY ONE (1) OF THE FOLLOWING ‘Otome sum CD rension D1 Lumpsum AND PENSION No.of Monty Pensions \Lump-sum Amount No.of Monthly Pensions: C, BENEFIT CLAIM THROUGH REPRESENTATIVE Thereby authorize the person whose signature appears below, Guy verted by me to Ne he benef ain forme INANE OF REPRESENTATIVE IN PRINT [SIGNATURE OF REPRESENTATIVE CERTIFICATION | erty that he information provided inthis form are rue and correct. (if member cannot sin, afc ‘ingerpits nthe prasence ofan SSS authorized offcer ) RIGHT THUMB ‘SIGNATURE OF MEMBER TC BENEFT CLAM RFORRATION "ACCOUNT SUMMARY. ONTRIBUTIONS Ci otsapproven D. Findings on identifcation documents: 1D Members not found tobe totally cisabied CW setted SPF Total Disability Claim OD otters: DATE a TIMETRSTRUCTIONS: Fill ou this form in one (1) copy without erasures and alterations, ‘Submit this form to the neargst SSS branch office. Review and confirm the information inthe accomplished and printed form provided by the SSS authorized office by personaly affixing signature or ‘thuromark (unable to sign) in the presence of an SSS authorized ofr. Total disability beneft amount shall be credited tothe SPF Member's envoled bank account in three (3) working days rom date of approval