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BMBR-119A Auto-Debit Arrangement Amendment Form
SSS form used for amendment of Auto - Debit arrangement
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Auto-Debit Arrangement
AMENDMENT FORM
Accomplish in three (3) copies.
Surname
First Name
EFFECTIVITY DATE:_______________
Middle Name
SS Number
NAME OF QUALIFIED SSS MEMBER
Please effect the following:
Change in Name:
Telephone No.
Change in Address:
Change in Bank Account No.:
SA
CHANGE
1.
DELETE
Housing Loan
Bank Branch
Bank Name
Amount
TERMINATE ENROLLMENT
Contribution
2.
ADD
CA
P
No.
Educational Loan (SNPL)
3
Emergency Loan
4
Calamity Loan
5
Stock Investment Loan
6
Loan:
Others (Specify):
Total
4.
Monthly Amort.
Salary Loan
2
Date to End Deduction
(mmddyy)
Loan Date
(mmddyy)
Loan Type
1
3.
P
REL Account Number:
P
Household Employer (HR)
SS Number
Date of
Birth
(mmddyy)
Employee Name
(Surname, Given Name, Middle Initial)
Loan Date
(mmddyy)
Monthly
Amortization
(I)
Monthly
Contribution
(II)
Total
GRAND TOTAL
Total
(I+II)
P
P
This is to amend the information stated in my enrollment form. The total amount to be deducted from my account will now be
_________________________________________________________________________________________________________ (P____________________)
I understand that the effectivity of this amendment is upon its approval.
CONFORME:
__________________________________________________________________________
Qualified Member’s Signature
_____________________________________
_____________________________________
Signature of Account Owner
(if other than Qualified Member)
FOR SSS USE ONLY
FOR BANK USE ONLY
Received/Verified by:
Received by:
Date
Date
Acct. No. & Signature Verified by:
Encoded by:
Date
Date
Approved by:
Approved by:
Date
Internet Edition (1/2014)
_________________
Date
READ TERMS AND CONDITIONS ON PAGE 2 OF THIS FORM
Date
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
and enforceable.
*The minimum salary credit for OFW is P5,000.
