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SSS P.E.S.O. Fund Payment Form
SSS payment form for P.E.S.O fund program
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
SOCIAL SECURITY SYSTEM
VPF-01218 (09-2015)
COV(11-2014)
SSS P.E.S.O. FUND
PAYMENT FORM
PLEASE READ THE INSTRUCTIONS BELOW BEFORE FILLING OUT THIS FORM.
PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK INK ONLY.
SS NUMBER
COMMON REFERENCE NUMBER (CRN)
(LAST NAME)
NAME
ADDRESS IN THE PHILIPPINES
(SUBDIVISION)
(THIS IS YOUR OFFICIAL RECEIPT WHEN VALIDATED)
DATE OF BIRTH (MMDDYYYY)
(FIRST NAME)
TAX IDENTIFICATION NUMBER
(MIDDLE NAME)
(RM./FLR./UNIT NO. & BLDG. NAME)
(SUFFIX)
(HOUSE/LOT & BLK. NO.)
(BARANGAY/DISTRICT/LOCALITY)
(CITY/MUNICIPALITY)
(STREET NAME)
(PROVINCE)
FOREIGN ADDRESS (IF APPLICABLE)
ZIP CODE
COUNTRY
TEL. NO. (COUNTRY CODE + AREA CODE + TEL. NO.)
MOBILE/CELLPHONE NO.
E-MAIL ADDRESS
SSS P.E.S.O. FUND PAYMENT
FORM OF PAYMENT
AMOUNT IN FIGURES
Cash
Check
AMOUNT IN WORDS
P
P
Bank Name/Branch
CERTIFIED CORRECT BY PAYOR
Check Number
Date
TOTAL AMOUNT
P
PRINTED NAME
SIGNATURE
DATE
INSTRUCTIONS
1. Fill out this form in two (2) copies without erasures and alterations.
2. Make all checks payable to SSS.
3. Submit this form with contribution payment to the nearest SSS Branch Teller.
Republic of the Philippines
SOCIAL SECURITY SYSTEM
VPF-01218 (09-2015)
SSS P.E.S.O. FUND
PAYMENT FORM
PLEASE READ THE INSTRUCTIONS BELOW BEFORE FILLING OUT THIS FORM.
PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK INK ONLY.
SS NUMBER
COMMON REFERENCE NUMBER (CRN)
(LAST NAME)
NAME
ADDRESS IN THE PHILIPPINES
(SUBDIVISION)
(THIS IS YOUR OFFICIAL RECEIPT WHEN VALIDATED)
DATE OF BIRTH (MMDDYYYY)
(FIRST NAME)
TAX IDENTIFICATION NUMBER
(MIDDLE NAME)
(RM./FLR./UNIT NO. & BLDG. NAME)
(HOUSE/LOT & BLK. NO.)
(BARANGAY/DISTRICT/LOCALITY)
(CITY/MUNICIPALITY)
FOREIGN ADDRESS (IF APPLICABLE)
(SUFFIX)
(STREET NAME)
(PROVINCE)
ZIP CODE
COUNTRY
TEL. NO. (COUNTRY CODE + AREA CODE + TEL. NO.)
MOBILE/CELLPHONE NO.
E-MAIL ADDRESS
SSS P.E.S.O. FUND PAYMENT
FORM OF PAYMENT
AMOUNT IN FIGURES
Cash
Check
AMOUNT IN WORDS
P
P
Bank Name/Branch
CERTIFIED CORRECT BY PAYOR
Check Number
Date
TOTAL AMOUNT
P
PRINTED NAME
INSTRUCTIONS
1. Fill out this form in two (2) copies without erasures and alterations.
2. Make all checks payable to SSS.
3. Submit this form with contribution payment to the nearest SSS Branch Teller.
SIGNATURE
DATE
