Republic of the Philippines | SOCIAL SECURITY SYSTEM LF | SSS P.E.S.0. FUND verre 0207 DEATH BENEFIT CLAIM FORM "THIS FORM WAY BE REPRODUGED AND IS NOT FOR GALE, THIS CAN ALSO BE DOWNLOADED AT THE S89 WEBSITE AT worw.ans.g0v ph. PLERSE READ THE NS ONLY. KN PART |- TO BE FILLED OUT BY THE CLAIMANT "A. MEMBER'S INFORMATION DDENTIFICATION NUMBER tui toy Rave TNT [SATEOF DEATH wmucaVeTy, [PLACE OF DEAT Teo aay 4 f_flst dof ENDER jovi STATUS OD widowed Decay Separates Cotes, B. BENEFICIARY'S INFORMATION i ONTACT RFOR EMAL ADDRESS Caries Cova Crema |Cisingie TELEPHONE NO. MOBILE NO. [SARK NAWETBRANCH _ BENEFIT CLAIM THROUGH REPRESENTATIVE Thereby authorize the parson whose sghature appears below. duly verfd by me 10 fe the benelt Gaim forme, [RAUE OF REPRESENTATIVE IN PRINT | certify thatthe information provided in tis fom are tue and correct. (if benaiciary canna sign fi. fingorantsin the presence of an SSS authorized ofr) RIGHT THUMB RIGHT INDEX ‘SIGNATURE OF BENEFICIARY Dn ra 7 BENEFT CAR NPORAATON a [BERTH SENEFIT ANOUNT LONP APPROVED ID. oisaPproven 1D Findings on identfcation documents: 1D Not decared beneticiany ‘SIGNATURE OVER PRINTED NAME C_witn settes S°F Death Claim win te same beneficary DB otters: DATES TE INSTRUCTIONS: FF out tis form in ona (1) copy winout erasures and aeration. ‘Submit his form othe nearest SSS branch ofce, Review and conti re ivoraten ne accomplished ad sf provided by he SSS auhazed tice by personaly fing sti oe rub ‘unable to sign) in the presence of an SSS authorized officer. " cs: ne Death benef amount shat be creed othe SPF beneficianys enrolled bank account i three (3) working days from date of approval