SEARCH
Philippine Government Forms All in One Location
Tweet
Share
Cooperative Member List
SSS form used to define cooperative members
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
ACCREDITATION NUMBER
SOCIAL SECURITY SYSTEM
COOPERATIVE MEMBER LIST
(07-2011)
(Please read instructions/reminders at the back. Print all information in black ink.)
EMPLOYER NUMBER
NAME OF COOPERATIVE
AREA CODE
BUSINESS ADDRESS
TELEPHONE NUMBER
POSTAL CODE
TYPE OF
MEMBERSHIP
NAME OF MEMBER
SS NUMBER
(Surname)
(Given Name)
(Middle Name)
DATE OF
BIRTH
SIGNATURE
HOME ADDRESS
SE
VM
We hereby allow the
Cooperative to collect
and
remit
our
contributions to the
SSS.
REMARKS
(For SSS Use)
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
)
11)
12)
13)
)
14)
15)
I CERTIFY TO THE CORRECTNESS OF ABOVE INFORMATION.
RECEIVED BY:
RECEIVING BRANCH:
TOTAL NO. OF
MEMBERS
Page ___ of ___ Page/s
Signature Over Printed Name
Official Designation
Date
Signature Over Printed Name
Date
Time
INSTRUCTIONS
1.
Submit this form in two (2) copies signed by the President/Chairman with the Cooperative Accreditation and the required documents
duly marked "a-m".
2.
Put a check mark on the applicable type of membership of each cooperative member.
3.
Write "Nothing follows" immediately after the last indicated cooperative member.
4.
Submit a new Cooperative Member List for additional cooperative members duly signed also by the Head of Cooperative.
REMINDERS
1.
The list shall be limited to the members of the cooperative who are self-employed and voluntary members of the SSS.
2.
Members in the list shall agree to avail the services of the Cooperative under the terms and conditions set in the Collection Agency
Agreement (CAA) by affixing their signatures opposite their names.
g
(
) y
g
g
pp
3.
Affixing the signatures on this form shall be a personal act of each cooperative member and shall not be delegated to others.
