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Pensioner's Reply Application Form
SSS annual confirmation of pensioner's form
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
SOCIAL SECURITY SYSTEM
ANNUAL CONFIRMATION OF PENSIONER'S FORM
PENSIONER'S REPLY
(02-2013)
THIS FORM IS NOT FOR SALE
PLEASE READ INSTRUCTIONS AND REMINDERS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS
AND USE BLACK INK ONLY.
PART I - MEMBER'S / PENSIONER'S INFORMATION
SS NUMBER OF PENSIONER
NAME
COMMON REFERENCE NO. (IF APPLICABLE)
(SURNAME)
LOCAL ADDRESS
DATE OF BIRTH (MMDDYYYY)
(GIVEN NAME)
(RM/FLR/ UNIT NO. & BLDG. NAME)
(BARANGAY/DISTRICT/LOCALITY)
(HOUSE/LOT/& BLOCK NO.)
(SUBDIVISION)
TELEPHONE NO. (AREA CODE + TEL. NO. )
(MIDDLE NAME)
(SUFFIX)
(STREET NAME)
(CITY/MUNICIPALITY)
MOBILE/CELLPHONE NO.
TIN (IF SELF-EMPLOYED/EMPLOYED)
(PROVINCE)
ZIP CODE
E-MAIL ADDRESS
FOREIGN ADDRESS (IF APPLICABLE)
COUNTRY
ZIP CODE
TYPE/S OF PENSION/S BEING RECEIVED. CHECK THE APPROPRIATE BOX/ES.
Retirement
SS Total Disability
SS Death
EC Total Disability
IF RECEIVING PENSION UNDER DEATH, INDICATE NAME/SS NO. OF DECEASED MEMBER
(SURNAME)
(GIVEN NAME)
(MIDDLE NAME)
(SUFFIX)
IF RECEIVING PENSION AS GUARDIAN, INDICATE NAME/SS NO. OF MEMBER
(SURNAME)
(GIVEN NAME)
(MIDDLE NAME)
EC Death
SS NO. OF DECEASED MEMBER
(SUFFIX)
SS NO. OF MEMBER
PART II - QUESTIONNAIRE
1. For total disability/retirement pensioner, have you been re-employed/resumed self-employment ?
Yes
No
If yes, name and address of present employer :
Date re-employed or resumed self-employment :
2. For death pensioner, have you re-married or currently cohabiting with another person ?
Yes
No
If yes, name of spouse/partner:
yes
Date of marriage/cohabitation:
3. Are you under the care and custody of a guardian?
Yes
No
If yes, name and address of guardian:
4. Is there any dependent child who already got married, employed or died ?
NAME OF DEPENDENT CHILDREN
NAME OF GUARDIAN, IF
APPLICABLE
Yes
No
If yes, fill out the data below:
DATE OF
DATE OF MARRIAGE
EMPLOYMENT
SS NO.
DATE OF DEATH
1
2
3
4
5
I hereby certify that the foregoing information is complete, true and correct to the best of my knowledge.
SIGNATURE OVER PRINTED NAME
OF PENSIONER
DATE
RIGHT THUMB
RIGHT INDEX
(If unable to sign, affix fingerprints with the signature of two witnesses and
submit photocopy of one valid ID with photo and signature of each witness)
Witnesses to fingerprints:
1)
2)
SIGNATURE OVER PRINTED NAME
DATE
SIGNATURE OVER PRINTED NAME
DATE
Left
PART III - CERTIFICATION OF BANK MANAGER/BARANGAY CHAIRMAN
(For Retiree and Survivor Pensioners)
Check the appropriate box (one only):
Bank Manager
Barangay Chairman
This
is
to
certify
that
Mr./Ms._____________________________________________,
a
depositor/bonafide
resident
of
__________________________________________________________________ personally appeared before the undersigned on ___________________________ as
compliance to the annual confirmation of pensioners being conducted by the Social Security System.
SIGNATURE OVER PRINTED NAME
DATE
NOTICE: Anyone who falsifies essential information requested by this or a related form may, upon conviction, be subject to fine and imprisonment under the
law (Sec. 28 (a) of the Social Security Law and Art.207 (b) Chapter IX of PD # 626).
For SSS Use Only
PART IV - DOCUMENTS SUBMITTED
Type of Compliance :
Personal
Thru Bank
Thru Representative
Thru Mail
Abroad
Incapacitated
Barangay Official
Institution
PENSIONER IS LIVING ABROAD
PENSIONER IS A LOCAL RESIDENT
Signed letter
Signed letter
Accomplished ACOP Form
Accomplished ACOP Form
Photocopy of valid passport
Sketch of residence
Photocopy of SS Card
Certification from
Photocopy of valid ID issued by host country governmental unit/
Barangay
agency (Pls. specify)
Institution
Photocopy of two (2) valid IDs (Pls. Specify)
Bank
1)
Medical Certificate
2)
Death Certificate
Medical Certificate
Complete physical examination report
Death Certificate
Relevant laboratory or diagnostic result
Complete physical examination report
SS Card
Relevant laboratory or other diagnostic exam results
Two (2) valid IDs (Pls. specify)
Certification issued by (Pls. specify)
1)_______________________
2)_______________________
ACTION TAKEN/REMARKS
Identity of pensioner established
For data capture
For interview (Lacks valid IDs for the issuance of SS No./Data Capture, etc.)
Deceased Pensioner
(Date of Death)
Others ________________________________________________
INTERVIEWED & SCREENED BY
SIGNATURE OVER PRINTED NAME
DESIGNATION
DATE
PART V - RECOMMENDATION
Continue
Suspend (Reason)___________________________________________________________________________________________
Cancel (Reason) ____________________________________________________________________________________________
Re-adjudicate (Reason) _______________________________________________________________________________________
Returned (Reason)
__________________________________________________________________________________________
Pending (For further evaluation)
X-ray/ECG for reading
For Medical Fieldwork Ser ices (MFS)
Field ork Services
For Fact of Pensioner's Existence (FPE)
For referral to other branch/unit
Others
REVIEWED & RECOMMENDED BY
SIGNATURE OVER PRINTED NAME
DESIGNATION
DATE
SIGNATURE OVER PRINTED NAME
DESIGNATION
DATE
APPROVED BY
This is your guide to accomplish the
ACOP Form
For Retiree or
Total Disability
Pensioner, fill
1
For Survivor
Pensioner,
Pensioner fill
out nos. 1 & 2
out no. 1
For Pensioner
under a
Guardian, fill out
nos. 1 & 3
2
3
ACKNOWLEDGEMENT RECEIPT
SS NUMBER OF PENSIONER
NAME OF PENSIONER
(SURNAME)
SS NUMBER OF MEMBER
NAME OF MEMBER
(SURNAME)
(GIVEN NAME)
(GIVEN NAME)
(MIDDLE NAME) (SUFFIX)
(MIDDLE NAME) (SUFFIX)
Please report for your Annual Confirmation anytime within your or member's birth month ; otherwise your pension will be suspended.
ISSUED BY:
SIGNATURE OVER PRINTED NAME
OF SSS PERSONNEL
DESIGNATION
DATE
