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PPS-KUR Kasambahay Unified Registration Form
SSS member application form for kasambahay
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: PPS-KUR FORM (V.1)
Republic of the Philippines
KASAMBAHAY
UNIFIED REGISTRATION FORM
(Pursuant to R.A. 10361 or the "Batas Kasambahay")
PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK OR
.BLUE INK ONLY. (Basahin ang mga Instructions sa likod ng Form bago ito sulatan. Isulat ang lahat ng impormasyon sa MALALAKING TITIK at gumamit lamang ng . ITIM o
ASUL na tinta.)
PART I - PLEASE INDICATE YOUR MEMBERSHIP NUMBER IF ALREADY REGISTERED
(Paki lagay ang inyong numero sa Pag-IBIG, PhilHealth or SSS kung myembro na)
Pag-IBIG MID Number/RTN
PHILHEALTH Identification Number (PIN)
SOCIAL SECURITY (SS) Number
PART II - A. PERSONAL INFORMATION
NAME
LAST NAME
(Apelyido)
FIRST NAME
(Pangalan)
NAME EXTENSION
(Ex. Jr. / II)
DATE OF BIRTH (MMDDYYYY)
SEX
(Kasarian)
CHECK IF NO MIDDLE NAME
(I-tsek ang kahon kung walang
gitnang pangalan)
CIVIL STATUS
(Araw ng Kapanganakan)
MIDDLE NAME
(Gitnang Pangalan)
(Sibil na Katayuan)
MALE
PLACE OF BIRTH
FEMALE
SINGLE
MARRIED
WIDOW/ER
LEGALLY SEPARATED
UMID COMMON REFERENCE NUMBER (IF AVAILABLE)
RELIGION
(CITY, PROVINCE, COUNTRY)
(Relihiyon)
(Lugar ng Kapanganakan)
MOTHER'S MAIDEN NAME
LAST NAME
(Apelyido)
(Pangalan ng Ina noong dalaga)
PRESENT ADDRESS
FIRST NAME
(Pangalan)
UNIT/RM./FLR. NO.
(Bilang ng Yunit at Palapag)
(Kasalukuyang Tirahan)
SUBDIVISION
(Subdibisyon)
NAME EXTENSION
(Ex. Jr. / II)
BUILDING NAME
(Pangalan ng Gusali)
LOT/BLK./HOUSE NO.
(Bilang ng Lote, Bloke, Bahay)
BARANGAY/DISTRICT
(Barangay/Distrito)
PERMANENT ADDRESS
UNIT/RM./FLR. NO.
(Bilang ng Yunit at Palapag)
(Permanenteng Tirahan)
SUBDIVISION
(Subdibisyon)
BUILDING NAME
(Pangalan ng Gusali)
ZIP CODE
PROVINCE/REGION
(Probinsya/Rehiyon)
LOT/BLK./HOUSE NO.
(Bilang ng Lote, Bloke, Bahay)
STREET NAME
(Kalye)
MUNICIPALITY/CITY
(Munisipyo/Syudad)
MOBILE/CELLPHONE NUMBER
CHECK IF NO MIDDLE NAME
(I-tsek ang kahon kung walang
gitnang pangalan)
STREET NAME
(Kalye)
MUNICIPALITY/CITY
(Munisipyo/Syudad)
BARANGAY/DISTRICT
(Barangay/Distrito)
TELEPHONE NUMBER (AREA CODE + TEL. NO.)
MIDDLE NAME
(Gitnang Pangalan)
PROVINCE/REGION
(Probinsya/Rehiyon)
ZIP CODE
E-MAIL ADDRESS
PART II - B. DEPENDENT/S OR BENEFICIARY/IES
SPOUSE
(Asawa)
LAST NAME
(Apelyido)
FIRST NAME
(Pangalan)
NAME EXTENSION
(Ex. Jr. / II)
Check if NO
Middle Name
MIDDLE NAME
(Gitnang Pangalan)
SEX ( Kasarian )
MALE
DATE OF BIRTH (MMDDYYYY)
(Araw ng Kapanganakan)
FEMALE
CHILD/REN
(Anak)
LAST NAME
(Apelyido)
FIRST NAME
(Pangalan)
NAME EXTENSION
(Ex. Jr. / II)
Check if NO
Middle Name
MIDDLE NAME
(Gitnang Pangalan)
CHECK IF W/
DISABILITY
DATE OF BIRTH (MMDDYYYY)
MALE
1.
(Araw ng Kapanganakan)
FEMALE
MALE
2.
FEMALE
MALE
3.
FEMALE
MALE
4.
FEMALE
MALE
5.
FEMALE
(Use another sheet if necessary)
FATHER
(Ama)
MOTHER
(Ina)
LAST NAME
(Apelyido)
FIRST NAME
(Pangalan)
NAME EXTENSION
(Ex. Jr. / II)
MIDDLE NAME
(Gitnang Pangalan)
Check if NO
Middle Name
CHECK IF W/
PERMANENT
DISABILITY
LAST NAME
(Apelyido)
FIRST NAME
(Pangalan)
NAME EXTENSION
(Ex. Jr. / II)
MIDDLE NAME
(Gitnang Pangalan)
Check if NO
Middle Name
CHECK IF W/
PERMANENT
DISABILITY
RELATIONSHIP TO REGISTRANT
OTHER BENEFICIARY/IES
LAST NAME
(Apelyido)
FIRST NAME
(Pangalan)
NAME EXTENSION
(Ex. Jr. / II)
Check if NO
Middle Name
MIDDLE NAME
(Gitnang Pangalan)
DATE OF BIRTH (MMDDYYYY)
(Araw ng Kapanganakan)
DATE OF BIRTH (MMDDYYYY)
(Araw ng Kapanganakan)
DATE OF BIRTH (MMDDYYYY)
(Araw ng Kapanganakan)
1.
2.
PART II - C. CERTIFICATION
I hereby certify that the information supplied above are true and correct for the purpose of my registration in the three (3) social security agencies
of the Philippine Government, namely, Pag-IBIG, PhilHealth & SSS.
(Ako ay nagpapatunay na ang aking mga isinaad sa itaas ay totoo at tama na nararapat para ako ay ma-rehistro bilang miyembro ng Pag-IBIG, PhilHealth at SSS.)
SIGNATURE OVER PRINTED NAME OF REGISTRANT
DATE
If registrant cannot sign, affix fingerprints to be witnessed by two (2) persons.
Below are the witnesses to fingerprinting:
1)
PRINTED NAME
SIGNATURE
DATE
PRINTED NAME
SIGNATURE
DATE
2)
RIGHT THUMB
RIGHT INDEX
PART III - TO BE FILLED OUT BY Pag-IBIG/PHILHEALTH/SSS
RECEIVED BY
Pag-IBIG
PHILHEALTH
SIGNATURE OVER PRINTED NAME
SSS
DATE & TIME
BRANCH
EVALUATED BY
FOR PHILHEALTH USE
SIGNATURE OVER PRINTED NAME
THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE
DATE & TIME
INSTRUCTIONS
A. Register to any of the Agencies (Pag‐IBIG/PhilHealth/SSS).
B. Submission of Documentary Requirements
* Not yet needed at the time of registration for the issuance of Pag‐IBIG/PhilHealth/SSS Numbers.
* If not available at the time of registration, registrant will still be provided the corresponding numbers. However, availments of any benefits shall only
be allowed upon submission of documents to prove his/her identity and payment of required premium contributions.
C. List of Acceptable Documents and Conditionalities:
For SSS Only
1. Primary Documents
Submit photocopy & present original/certified true copy of any of the ff:
* Birth Certificate
* Baptismal Certificate
* Drivers License
* Passport
* Professional Regulation Commission (PRC) Card
* Seaman's Book
2. Secondary Documents
In the absence of Primary Documents, submit photo copy and present original/certified true copy of TWO (2) of the following, BOTH should
bear the name and at least ONE (1) should indicate the Date of Birth:
* ATM Card
* Bank Account Passbook
* Birth/Baptismal Certificate of Children
* Marriage Contract
* NBI Clearance
* Police Clearance
* Postal ID Card
* Voter's ID/Affidavit
* School Records
* ID Card issued by Local Government Units (e.g. Barangay, Municipal/City)
If the required supporting document/s is/are not available at the time of registration, or if registration is done at Pag‐IBIG/PhilHealth, or if the
Registrant is unavailable to sign the document, SS Number shall still be issued, subject to the following conditions:
* Membership Status of Kasambahay is "Temporary".
* The SS Number issued can only be used for contribution payment and
employee reporting (by the Household Employer).
* Submission of Primary or Secondary document/s and/or signature in the
Form is required for conversion of Membership Status to Permanent,
thru Member's Data Amendment Form (SSS Form E‐4)
* Availment of SSS Benefits and Loans is only allowed for Permanent
Membership Status, subject to qualifying conditions.
D. Updating/Change in Personal Information, Dependents/Beneficiaries should be submitted to each agency (Pag‐IBIG/PhilHealth/SSS).
E. This form is not applicable for Family Driver. Registration of Family Driver should be done in each agency (Pag‐IBIG/PhilHealth/SSS).
