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Sickness and Maternity Benefits Payment Thru The Bank

SSS form used for Employment - enrollment of the employer in the Sickness & Maternity Benefits Payment thru Bank program. Exemption - employers who prefer to receive their reimbursements through checks. Amendment - changes or amendments in the employer?s bank account information and Cancellation - cancellation of employer's enrollment in the program due to closure of employer?s bank account or employer has ceased or temporarily suspended its operation.

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SOCIAL SECURITY SYSTEM

SICKNESS AND MATERNITY BENEFITS
PAYMENT THRU THE BANK FORM

(12-2013)

THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE
PLEASE READ THE INSTRUCTIONS AND REMINDERS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND

USE BLACK OR BLUE INK ONLY.
PART I -TO BE FILLED OUT BY EMPLOYER
A. EMPLOYER INFORMATION
TYPE OF TRANSACTION:

Enrollment

EMPLOYER NUMBER

Exemption

Amendment

EMPLOYER NAME

EMPLOYER ADDRESS

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

(SUBDIVISION)

(HOUSE/LOT & BLK. NO.)

(BARANGAY/DISTRICT/LOCALITY)

TELEPHONE NUMBER (AREA CODE + TEL. NO.)

Cancellation

TAX IDENTIFICATION NUMBER

(STREETNAME)

(CITY/MUNICIPALITY)

(PROVINCE)

E-MAIL ADDRESS

ZIP CODE

WEBSITE

B. BANK ACCOUNT INFORMATION
NAME OF BANK

BANK ACCOUNT NUMBER

TYPE OF ACCOUNT
Savings

BANK BRANCH ADDRESS

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

(SUBDIVISION)

(HOUSE/LOT & BLK. NO.)

(BARANGAY/DISTRICT/LOCALITY)

(CITY/MUNICIPALITY)

Current
(STREETNAME)

(PROVINCE)

ZIP CODE

AUTHORIZED/DESIGNATED BANK ACCOUNT SIGNATORY/IES
NAME

POSITION TITLE

SIGNATURE

(LAST NAME) (FIRST NAME) (MIDDLE NAME)

C. EMPLOYER CERTIFICATION

I certify that the information provided in this form are true and correct. Also, I certify that I understood the Instructions and Reminders
indicated at the back of this form.

PRINTED NAME OF AUTHORIZED SIGNATORY

SIGNATURE

POSITION TITLE

DATE

POSITION TITLE

DATE

PART II -TO BE FILLED OUT BY BANK

I certify the correctness of the bank account information indicated by the employer herein.

PRINTED NAME

SIGNATURE
PART III -TO BE FILLED OUT BY SSS

FOR ENROLLMENT, AMENDMENT & CANCELLATION

FOR EXEMPTION

RECOMMENDATION

REASON

APPROVED

Location is far from the bank/high risk area

Enrollment

BRSTN

Amendment

Number of employees of employer is less than 5

BRSTN

Employer cannot afford the average daily balance required by the bank
(IF CHANGE OF BANK/BANK BRANCH)

Others _______________________________________________

_____________________________________

Cancellation
REJECTED (see reason/s at the back)

RECOMMENDATION
APPROVED
DISAPPROVED
Reason _______________________________________________
_____________________________________________________

PROCESSED BY

SIGNATURE OVER PRINTED NAME

REVIEWED BY

DATE & TIME

SIGNATURE OVER PRINTED NAME

CONFIRMED BY (FOR EXEMPTION TRANSACTION)

DATE & TIME

SIGNATURE OVER PRINTED NAME

DATE & TIME

INSTRUCTIONS AND REMINDERS

1. Fill out this Form in two (2) copies without erasures and alterations.
2. Place a checkmark on the applicable box.
3. Always indicate "N/A" or "Not Applicable", if the required data is not applicable.
4. Use this Form for any of the following purposes:
§ Enrollment - enrollment of the employer in the Sickness & Maternity Benefits Payment thru Bank program
§ Exemption - employers who prefer to receive their reimbursements through checks
§ Amendment - changes or amendments in the employer’s bank account information
§ Cancellation - cancellation of employer's enrollment in the program due to closure of employer’s bank account or employer has
ceased or temporarily suspended its operation
5. For Application for Enrollment and Amendment, accomplish Part I (A to C) of the Form and submit to your designated SSSaccredited bank. The bank shall certify the correctness of the bank account information and shall forward the Form to SSS.
The bank account signatory/ies specified in this Form shall be the official designated by the employer or the company's Board of
Directors as its authorized signatory as appearing in the bank's records.
6. For Application for Exemption and Cancellation, accomplish Part I (A & C) of the Form and submit to any SSS branch office.
7. The Form shall be signed by the authorized company official who is certified by the employer in the Specimen Signature Card (SSS
Form-L501) as the designated signatory.
8. Status of the enrollment/exemption/amendment/cancellation in the program may be verified through the Online Inquiry accessible
from MY.SSS web account of the SSS Website at http://www.sss.gov.ph
9. Upon approval of the enrollment to the program, all sickness and maternity reimbursements shall be credited to the employer's bank
account. Details of payment can be accessed through the SSS Web Inquiry System and through the Online Inquiry accessible from
MY.SSS web account of the SSS Website at http://www.sss.gov.ph
10. Notify SSS of any change in the bank account information or closure of the bank account immediately by accomplishing this form, to
avoid delay in the processing of reimbursement claims.
11. In case of revocation of bank’s accreditation with SSS, the employer shall be notified by SSS to open an account at other SSSaccredited bank under this program to avoid delay in the processing of reimbursement claims.
12. In case of bank closure or bank holiday, the benefit reimbursements remitted to the employer’s bank account shall be governed by the
banking rules and regulations.

FOR REJECTED APPLICATION

We are returning your application for Sickness & Maternity Benefits Payment thru the Bank Program due to the deficiency/ies as
indicated below:

Please refile this Form upon compliance of discrepancy/ies.
PROCESSED BY

Signature Over Printed Name

Date & Time

WARNING
ANY PERSON WHO MAKES ANY FALSE STATEMENT IN THIS APPLICATION OR SUBMITS ANY FALSIFIED DOCUMENT IN CONNECTION WITH
THE APPLICATION WITH THE SSS SHALL BE LIABLE CRIMINALLY UNDER SECTION 28 OF R.A. 8282 OR UNDER PERTINENT PROVISION OF
THE REVISED PENAL CODE OF THE PHILIPPINES.
 
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