SELF-DEGLARATION FORM OF SURVIVOR PENSIONER ON NON-REMARRIAGENON COHABITATION es {tobe fied ut by SURVIVOR PENSIONER ONLY) 10 hereby deciare that | have not remarried, cot a: soa ae ears al remaried,cohablaled with another parson, or aherwee engaged na common-law eatonsip since th | understand that sid declaration as gion by me i proven fo be fie, ny anfemant foe death benefit of my seause fom the Soci PME scart Msc nasysraaysime Ao Meee tes also ackrawledo hat once rma, cohabit wit acy pact, o and applicable SSS policy shall be implemented, “pe ae In.a commoniaw relaonship, | shal report the same to the SSS; deta om ot 889, wo ed of demande id a = ‘without need of demand or judicial action, all undue pension benefits that | may have rec ee ‘entitlement thereto has been cancelled as stated above, é: aes % oak further acknowedge that ary misrepresentation, concealment an . aground fr criminal 4 fNeferletineerg mont and inaccurate or uriuthfl statement on my part shal be aground LEA Ve HALULG __ Holi ocfer/r3 PRINTED NAME OF SURVIVOR PENSIONER SIGHATURE por Fr CERTIFICATION AND DATA PRIVAOY NOTICE & AGREEMENT Tety that the information provided in this form are true and core. \agre that the information coleced trough his form sabe used ad elaine by he SSS forthe processing and coninuous payment of tension fo the establetert errs ce dtente of S86 aga came and reetablsh of comin the operators ofthe SSS in the event of easter may ge copy oe for and comet ous ary omaton aan. Furbomore | undertand tat | oon SSS pensioner. eal bo subiet lec vrieaon processes a eq bythe SSS io enero TY sity asin te Cat punta vrakcnat nel fhe earn posse ta ogres ager pase ay 85 Dae Provided, rer, tha S58 aha conduct a home vt al oop upon he reaues of 98S Tndertand tha pursuant Se. 24 (c, SS Ae of 2018 Repub Act (A) No. 1110] andthe ala Pvacy Ac of 2042 (RA, No_ 1017) tho SSS shal keep conintel sd cecal te formation ising ogazatonl physical end teciical measures and procedures. | also cesta at SS wnt cle my peaoral Gla ay peran nes | atte he sme or eqs trough a subpoenaed cout orquasijitil bode, However agree frthe SS fo share my information wih ater goverment agereie ks, the Pavel. Poo, Tore hone Stkesce Aso, Copan af Socal Wlare rd Daveapnet and Cormision on Aut, rough a ela shang agreement try contact wih partner private companies tk, berks Soe eer caarin or eons cores, forthe provson of =n Sredaglans eisant sorven onder tamer ot SSS" mapéateo povie ec sciry LIA Vv HALLIG : oth2/e3 PRINTED WANE OF PERSIONERIGUARDIAN Scarone Dare it pensioneriguardian cannot sgn, afc figerprints. Winessos to fogerprintng [To be accomplished by SSS perscnneliuthorizedrepresenative Ut fled thru opresentatve) PRINTED NAME DATE POSITIONIRELATIONSHIP. ‘SSS BRANCHIAUTHORIZED REPRESENTATIVE'S ADDRESS: RIGHT THONG, ich INDEX. PARTI-TO BE FILLED OUT EY SSS, “A: MANNER OF COMPLIANCE, IT PERSONAL APPEARANGE —CI-THRU AUTHORIZED REPRESENTATIVE —__CUTHRUWAL CUTHRUENAL [] THRUDROPGOX 1 SCREENING RESULTS ler ennt ot pensionarTierreesantalve esabicned CT Deceased Pensioner Takes z: IG Foraata capture Date of Death i 1G For further interview INTERVIEWED ANDIOR SCREENED BY PRINTED NAME SIGNATURE PORTTIONTITE TRATES TE Cc ‘C RECOMMENDATION IS conan Ce ra nian | a eee c i 1 For Medical Fieldwork Servicas/Fact of Pensioner's Existence I Suspend (Reason’s) Bo Others (Reason! I cancel (Reason‘s) 5 Re-adjudicate(Reason/s) REVIEWED AND RECOWMENDED BY i | PRINTED NAME [APPROVED BY ‘SIGNATURE POMTONTITIE PRINTED NAME ip Peas Pot Jana Confirmation of Pensioners (Pensioners ReoRepublic ofthe Philippines. SOCIAL SECURITY SYSTEM ANNUAL CONFIRMATION OF PENSIONERS 7 (PENSIONER'S REPLY) ae eu = BE REPRODUCED AND IS NOTFOR SALE, THIS CAN ALSO BE DOWNLOADED THRU THE SSS WEBSITE AT www. Pose SATTRGHED INSTRUCTIONS BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK 4 PEN-01718 (08-2022) PARTT-TO BE FILLED OUT BY PENSIONERIGUARDIAN JTYPE OF PENSION CIEGK APPROPRIATE ON ()_ RETIREMENT SS PERMANENT TOTAL DISABILITY (C)_EC PERMANENT TOTAL DISABILITY, 7] SS DEATH. DEC DEATH LS EOE SSNOWEER coe Sara ere ETS aa 13| 4815 171-3) lal HALL Io AWACLETO TORRES SR B. PENSIONER'S DATA. ISS NUMBER (FAN) [SOMMON REFERENCE NUMBER FA) IDATE OF BIRTH OM OOYYYY) [TAXPAYER ID NUMBER (FANT) Pertenmenele| tit ttt Llaslon og el | tt [ae HALLIO LEA VILL Are | ELA reer LEON” SER Re TOES Caer aKT SETS sae CS SUE JO. pI NO STOTT rm rom BOSAL COOE AN MARTIN DE Por eéS PARATIAOUE poerreo_bIAss/ LA AAA pastime pest avpooness FZ CG ANAS AS| allin @yahoo: com. A Oe Se ea TE LEA vy. HALLIO fe ge | GUARDIANS DATA a SSNOMEER mero il iil SATE GE BIRTH ORDOFTD IRAME (CST WARY FRET eae ra [POSTAL CODE Fo the dependent (minorincapactaied) chad under your care and ustody aready married, deceased or omployed/setremployed? a ver pene ute peal at i we : IEF TRE OF SRE OF ENPLOTHENTT : varsence DEATH SELF-EMPLOYMENT oe eur Sree EHPLOVED) een oman eS ‘ enigeemerecr erent Sy QUESTIONNAIRE [FOR PENSIONER ONLY) Foran (otang sroraipermanent 1D Yes, please inicate the fotowin: “ial ainabiity panaloner, have you been re-employedihave you resumed rempoyment? ON —DRTE OF REEMPLOYMENTT | NAME OF [ADDRESS OF RESUMPTIONOF — | EMPLOYERIBUSINESS EWPLOYERIBUSINESS. SELFEMPLOYNENT | onenosrem For Se Le STI sarvivor penaloner, have you re-maried or curently cohabiing or nga Jo in a vein relationstip with another person?” Li Yes, pease indicate the folowing: IAIN, plenee tt fam E Raeon DATE OF RE-MARRIAGE OR ‘SPOUSE/PARTNER COHABITATION waco ea | riires (eniding abroadypermanent total daabiliy/survivor ‘Yes, ploase fl out the applicable data below ‘Pensioner leave there any dependent (minorincapactated) children under your care and custody? ONo awe oF DEPENDENT paTeor ATE oF EMPLOYMENT? (MINORJINCAPACITATED) CHILOIREN ‘SSNUMBER BSR GE: ‘SELF-EMPLOYMENT ts Misiones] esos ale en 3 i a {aN Se aS P| TEL ELENE| . (eLSIS (BIAS ]3) | : ad TL “Annual Confirmation of Pensioners (Pensioners Reply) Page 1