SSS P.E.S.O. Fund Payment Form

SSS payment form for P.E.S.O fund program

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SOCIAL SECURITY SYSTEM
VPF-01218 (09-2015)
COV(11-2014)

SSS P.E.S.O. FUND
PAYMENT FORM

PLEASE READ THE INSTRUCTIONS BELOW BEFORE FILLING OUT THIS FORM.
PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK INK ONLY.
SS NUMBER

COMMON REFERENCE NUMBER (CRN)
(LAST NAME)

NAME

ADDRESS IN THE PHILIPPINES
(SUBDIVISION)

(THIS IS YOUR OFFICIAL RECEIPT WHEN VALIDATED)

DATE OF BIRTH (MMDDYYYY)

(FIRST NAME)

TAX IDENTIFICATION NUMBER

(MIDDLE NAME)

(RM./FLR./UNIT NO. & BLDG. NAME)

(SUFFIX)

(HOUSE/LOT & BLK. NO.)

(BARANGAY/DISTRICT/LOCALITY)

(CITY/MUNICIPALITY)

(STREET NAME)

(PROVINCE)

FOREIGN ADDRESS (IF APPLICABLE)

ZIP CODE

COUNTRY

TEL. NO. (COUNTRY CODE + AREA CODE + TEL. NO.)

MOBILE/CELLPHONE NO.

E-MAIL ADDRESS

SSS P.E.S.O. FUND PAYMENT
FORM OF PAYMENT

AMOUNT IN FIGURES

Cash
Check

AMOUNT IN WORDS

P
P

Bank Name/Branch

CERTIFIED CORRECT BY PAYOR

Check Number
Date
TOTAL AMOUNT

P

PRINTED NAME

SIGNATURE

DATE

INSTRUCTIONS
1. Fill out this form in two (2) copies without erasures and alterations.
2. Make all checks payable to SSS.
3. Submit this form with contribution payment to the nearest SSS Branch Teller.

Republic of the Philippines

SOCIAL SECURITY SYSTEM
VPF-01218 (09-2015)

SSS P.E.S.O. FUND
PAYMENT FORM

PLEASE READ THE INSTRUCTIONS BELOW BEFORE FILLING OUT THIS FORM.
PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK INK ONLY.
SS NUMBER

COMMON REFERENCE NUMBER (CRN)
(LAST NAME)

NAME

ADDRESS IN THE PHILIPPINES
(SUBDIVISION)

(THIS IS YOUR OFFICIAL RECEIPT WHEN VALIDATED)

DATE OF BIRTH (MMDDYYYY)

(FIRST NAME)

TAX IDENTIFICATION NUMBER

(MIDDLE NAME)

(RM./FLR./UNIT NO. & BLDG. NAME)

(HOUSE/LOT & BLK. NO.)

(BARANGAY/DISTRICT/LOCALITY)

(CITY/MUNICIPALITY)

FOREIGN ADDRESS (IF APPLICABLE)

(SUFFIX)

(STREET NAME)

(PROVINCE)

ZIP CODE

COUNTRY

TEL. NO. (COUNTRY CODE + AREA CODE + TEL. NO.)

MOBILE/CELLPHONE NO.

E-MAIL ADDRESS

SSS P.E.S.O. FUND PAYMENT
FORM OF PAYMENT

AMOUNT IN FIGURES

Cash
Check

AMOUNT IN WORDS

P
P

Bank Name/Branch

CERTIFIED CORRECT BY PAYOR

Check Number
Date
TOTAL AMOUNT

P

PRINTED NAME
INSTRUCTIONS

1. Fill out this form in two (2) copies without erasures and alterations.
2. Make all checks payable to SSS.
3. Submit this form with contribution payment to the nearest SSS Branch Teller.

SIGNATURE

DATE