Philippine Government Forms All in One Location
BMBR-119A Auto-Debit Arrangement Amendment Form
SSS form used for amendment of Auto - Debit arrangement
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Accomplish in three (3) copies.
NAME OF QUALIFIED SSS MEMBER
Please effect the following:
Change in Name:
Change in Address:
Change in Bank Account No.:
Educational Loan (SNPL)
Stock Investment Loan
Date to End Deduction
REL Account Number:
Household Employer (HR)
(Surname, Given Name, Middle Initial)
This is to amend the information stated in my enrollment form. The total amount to be deducted from my account will now be
I understand that the effectivity of this amendment is upon its approval.
Qualified Member’s Signature
Signature of Account Owner
(if other than Qualified Member)
FOR SSS USE ONLY
FOR BANK USE ONLY
Acct. No. & Signature Verified by:
Internet Edition (1/2014)
READ TERMS AND CONDITIONS ON PAGE 2 OF THIS FORM
TERMS AND CONDITIONS
1. The instruction and /or information in this Amendment Form shall supersede the instructions and/or information
contained in your Enrollment Form.
2. This Amendment shall take effect only upon the approval by the SSS and by the BANK and that once the same is
approved within the 1st day to the 15th day of the month of application, the change shall take effect on the succeeding
month. In the event that the Amendment is approved on the 16th day of the month onwards, the change shall take
effect on the month after the succeeding month.
3. All other terms and conditions contained in the original enrollment form not contrary hereto shall remain valid
*The minimum salary credit for OFW is P5,000.