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BMBR-119A Auto-Debit Arrangement Enrollment Form

SSS application form for Auto - Debit Arrangement

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ENROLLMENT FORM

SSS FORMBmbr-119(1/94)

Accomplish in three (3) copies.
Surname

NAME OF QUALIFIED SSS MEMBER

EFFECTIVITY DATE:___________________

First Name

Middle Name

ADDRESS

SS Number

DATE OF BIRTH (mm dd yy)

TELEPHONE NUMBER
BANK NAME

Zip Code
BANK BRANCH

1. CONTRIBUTION

2. HOUSING LOAN

MEMBERSHIP & TRANSACTION TYPE
[ ] SELF-EMPLOYED
[ ] OTHERS: (Specify) _________________________________
[ ] OVERSEAS FILIPINO WORKER: COUNTRY CODE:__________
[ ] VOLUNTARY MEMBER

Amount

P

1

Educational Loan (SNPL)

3

Emergency Loan

4

Calamity Loan

5

Stock Investment Loan

6

Monthly Amort.

Salary Loan

2

Date to End Deduction
(mmddyy)

Loan Date
(mmddyy)

Loan Type

Others (Specify)
Total

4. HOUSEHOLD EMPLOYER
SS Number

Savings

P

Real Estate Loan Acct. No.:

No.

3. LOAN

Account Type
Current

Bank Account Number

P

(Attach additional sheet if necessary)
Employee Name
(Surname, Given Name, Middle Initial)

Date of
Birth
(mmddyy)

Loan
Date/Type
(mmddyy)

Monthly Loan
Amortization
(I)

Monthly
Contribution
(II)

Total
GRAND TOTAL (1+2+3+4)

Total
(I+II)

P
P

I hereby authorize the above stated bank to automatically deduct from my account the grand total amount of _____________________________
__________________________________________ (P ___________________) due me and to remit the same to SSS monthly.
It is hereby understood that the information contained herewith shall remain in force until the necessary corrections/changes
are made in writing and I hereby agree to be bound by the terms and conditions printed in the reverse hereof or any amendment thereto.

________________________________________ Conforme:___________________________________
Qualified Member’s Signature
Signature of Account Owner
(if other than Qualified Member)

FOR BANK USE ONLY

FOR SSS USE ONLY
Received/Verified by:

Received/Verified by:

Date

Date
Encoded by:

Acct. No. & Signature Verified by:

Date
Approved by:

Date
Approved by:

Date
Internet Edition (1/2014)

_______________
Date

PLEASE READ TERMS AND CONDITIONS ON PAGE 2 OF THIS FORM

Date

TERMS AND CONDITIONS GOVERNING THE AUTO-DEBIT ARRANGEMENT (ADA)
1. As used herein, the words “QUALIFIED SSS MEMBER” means the SELF-EMPLOYED (SE), VOLUNTARY (VM),
HOUSEHOLD EMPLOYER (HR) and OVERSEAS FILIPINO WORKER (OFW) members of the SSS and its SALARY &
HOUSING LOAN BORROWERS.
2. MEMBERSHIP. In order for a Qualified SSS Member to enroll under the arrangement, he shall have first opened and shall
maintain the deposit (current or savings) account indicated in the reverse hereof with the BANK and the written instruction herein
to the SSS shall authorize the BANK concerned to have his payments for the SSS contributions and/or loan amortizations, as the
case may be automatically debited from the said account.
Said instructions on the reverse hereof shall serve as the basis for the debiting of a member’s account by the BANK, and unless
informed in writing by the SSS of any changes therein, the foregoing shall continue to be in full force and effect.
The BANK shall ensure that the data pertaining to the BANK Account indicated herein are complete, valid, and accurate and
that the Qualified SSS Member enrolling under the Arrangement has been authenticated by the BANK to be its legitimate depositor.
SSS shall pre-validate all enrollment forms to be submitted by the BANK. Qualified SSS Members shall be notified in writing
by the SSS of the status of their enrollment.
3. EFFECTIVITY. The Qualified SSS Member whose enrollment form is approved by both the SSS and the Bank during the 1st
day to the 20th of the month shall be included on the same month and a Member whose enrollment form is approved by the SSS and
the BANK during the 21st day onwards shall be included on the succeeding month.
4. BILLING. The BANK is hereby authorized by the Qualified SSS Member to debit on the 10th day of the month from his
account the amount in the collection and/or billing lists to be provided by the SSS. Any discrepancy between the amount advised
and the amount debited per SSS record(s) or any complaint arising from this ADA shall be taken directly by the Qualified SSS
Member with the SSS.
5. PAYMENT CERTIFICATE. The Qualified SSS Member may request a certificate of payments, whenever needed, either
from the SSS or the BANK.
6. AVAILABILITY OF FUNDS. The Qualified SSS Member guarantees to maintain the deposit account indicated on the reverse
hereof of the funds necessary to cover this debit instruction. In the event the member fails to maintain the necessary funds in his
account to cover his payment for a particular month, the BANK shall be under no obligation to debit on the succeeding month the
corresponding amount. Such delayed payment shall be made by the member directly to the bank.
7. AMENDMENTS. The Qualified SSS Member who wishes to have changes in his enrollment data should inform the SSS or
the BANK in writing by filling up the Auto-Debit Arrangement Amendment Form. Amendment(s) shall take effect the same manner
as provided for in the enrollment application as mentioned above.
8. Please follow NEW SSS SCHEDULE OF CONTRIBUTIONS below:

*The minimum salary credit for OFW is P5,000.
 
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