Republic of the Philippines SOCIAL SECURITY …

1 DDR-1 Rev. 03-99 Republic of the PhilippinesSOCIAL SECURITY SYSTEMDEATH, DISABILITY AND RETIREMENT CLAIM(Please read instructions at the back. Print all information in capital letters & use black ink only.)SS NUMBERNAME OF MEMBER(SURNAME)(GIVEN NAME)(MIDDLE NAME)ADDRESS(NUMBER & STREET)(BARANGAY)(TOWN/DISTRICT)(CITY/PR OVINCE)POSTAL CODEDATE OF BIRTH(MM/DD/YYYY)PLACE OF BIRTH(TOWN/DISTRICT)(CITY/PROVINCE)CIVIL STATUSSINGLEMARRIEDWIDOWTELEPHONE TYPED isabilityRetirementOpt to receive first 18 monthly pension in lump of a retiree or a total disability pensionerSSECDate of Death(MM/DD/YYYY)EMPLOYMENT HISTORYNAME OF EMPLOYERADDRESSPERIOD OF CHILDREN(BEGINNING FROM THE YOUNGEST)DATE OF BIRTH(MM/DD/YYYY)Check Applicable OF BANK/BRANCHBANK ADDRESSACCOUNT NUMBERBRSTNI CERTIFY:1. That the above-mentioned children are under my care and custody;2. That I am competent to receive in behalf of the said children the amount due them as dependents of the subject member of the SSS;3.

2 That I have not abandoned, neglected or refused to support said children, nor caused them to commit offenses against the law;4. That none of the aforesaid children are married or employed;5. That I will immediately notify the SSS should any of the above listed children die, marry or become employed, and;6. That all information stated herein are SSS USECERTIFICATION OF SEPARATION FROM LAST EMPLOYERP hoto1 x 1 NAME OF CLAIMANT(SURNAME)(GIVEN NAME)(MI)DATE OF BIRTH (MM/DD/YYYY)RELATIONSHIP TO MEMBERCERTIFICATIONS ignatureDateSignature Over Printed NameDateSignature Over Printed ThumbprintRight IndexEMPLOYER ID NUMBERNAME OF EMPLOYERADDRESSI certify that the employee named herein was separated from our employ on OVER PRINTED NAME OF EMPLOYER/AUTHORIZED REPRESENTATIVEDATEOFFICIAL DESIGNATIONNO OTHERCLAIM FILEDCLEARED / DATE:RECEIVED / DATE:REMARKS:Signature Over Printed NameSignature Over Printed NameWITNESSES TO THUMBPRINT (If claimant cannot sign)Internet Edition (7/2000)GENERAL INSTRUCTIONS1.

3 Accomplish this form in one copy without erasures or Submit photocopies together with the original or certified true copy of birth/baptismal/marriage/deathcertificat e for Submit photocopy together with the original single savings account PERSON WHO MAKES ANY FALSE STATEMENT IN THIS APPLICATION OR SUBMITS ANY FALSIFIEDDOCUMENTS IN CONNECTION WITH THIS CLAIM SHALL BE CRIMINALLY LIABLE FOR FALSIFICATION OF OF REQUIRED DOCUMENTSSPECIFIC INSTRUCTIONSDEATHP rimary BeneficiariesDeath Certificate of member-Should be duly registered with Local Civil Registry s Affidavit-To be accomplished by the person actually filing the Certificate-Should be duly registered with Local Civil Registry Office/ Certificates of minors-Should be duly registered with Local Civil Registry Office/ Certificate of incapacitated child, if any-To be accomplished by the child s attending Certificate of spouse-To be submitted if spouse is for Representative Payee (CLD-15)-To be accomplished by the guardian of the minor children otherthan the Bond Form (BPN-107)-To be accomplished by a guarantor, if minor children are undera Report/Report of Death (BPN-105)-To be secured from the of relationship such as record of birth,-To be submitted for illegitimate statement before a court of record of anyauthentic writing/documentSecondary Beneficiaries If Claimant is Parent.

4 Death Certificate of member-Should be duly registered with Local Civil Registry s Affidavit-To be accomplished by the person actually filing the for Death Benefit Claim ( )-To be executed by the Certificate of Deceased member-Should be duly registered with Local Civil Registry Office/ Certificate of parents-Should be duly registered with Local Civil Registry Office/ Report/Report of Death (BPN-105)-To be secured from the employer. If Claimant is other than Parents:Joint Affidavit ( )-To be executed by two persons of legal age and preferably closerelatives of the Certificate of parents-To be submitted if parents are Certificate of the deceased brother/sister-To be submitted to prove claimant s relationship with Certificate of minor beneficiaries-Should be duly registered with Local Civil Registry Office/ for Representative Payee (CLD-15)-To be accomplished by the guardian of the minor children otherthan the Bond Form (BPN-107)-To be accomplished by a guarantor, if minor children are undera Certificate (MMD-102)-To be accomplished by the claimant s attending Room Record-To be secured if claimant has been operated Report (B-309)

5 -To be secured from the of Guardianship-To be accomplished by the guardian of incapacitated medical records that may be requested bythe Medical Services, QC Branch/Medical BenefitsMedical Certificate of incapacitated child, if any-To be accomplished by the child s attending Contract-To be submitted if with children below 21 years old Certificate of Dependent-Should be duly registered with Local Civil Registry Office/Parish/minor Certificate of incapacitated child, if any-To be accomplished by the child s attending Certificate of member-To be submitted if with discrepancy in the date of of business closure-To be submitted if self-employed member is below 65 years of separation (Form E-47)-To be submitted if last employer has closed business operation.