Share

Unified Multi-Purpose ID Card Application Form

SSS form used in applying for initial or replacement UMID card

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines

UNIFIED MULTI-PURPOSE ID (UMID) CARD
APPLICATION FORM

(07-2013)

THIS FORM IS NOT FOR SALE AND CAN BE REPRODUCED
PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK OR
BLUE INK ONLY.
NAME OF AGENCY

COMMON REFERENCE NUMBER (IF ANY)

SOCIAL SECURITY SYSTEM
PURPOSE
INITIAL ENROLLMENT

CARD REPLACEMENT
Replacement of Lost Card

Amendment of Facts of Birth
Amendment of Demographic Data

Replacement of Damaged Card
Amendment of Name

Others ____________________
__________________________

Amendment of Authenticating Finger

PART I - NAME
(LAST NAME)

MAIDEN NAME

(FIRST NAME)

(MIDDLE NAME)

(SUFFIX)

(LAST NAME)

1. NAME

(FIRST NAME)

(MIDDLE NAME)

(SUFFIX)

(IF MARRIED FEMALE)

PART II - FACTS OF BIRTH
2. DATE OF BIRTH (MMDDYYYY)

(CITY/MUNICIPALITY)

3. PLACE OF BIRTH

(PROVINCE/STATE)

(COUNTRY, If born outside the Philippines)

4. SEX
MALE

FEMALE

5a. FATHER'S NAME

(LAST NAME)

(FIRST NAME)

(MIDDLE NAME)

(SUFFIX)

5b. MOTHER'S MAIDEN NAME

(LAST NAME)

(FIRST NAME)

(MIDDLE NAME)

(SUFFIX)

(STREET NAME)

(SUBDIVISION)

PART III - DEMOGRAPHIC DATA
6. HOME ADDRESS

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

(BARANGAY/DISTRICT/LOCALITY)

(HOUSE/LOT & BLK. NO.)

(CITY/MUNICIPALITY)

(PROVINCE/STATE)

ZIP CODE

COUNTRY CODE

7. MARITAL STATUS
SINGLE
MARRIED
WIDOWED
DIVORCED/ANNULED
8. TAX IDENTIFICATION NUMBER 9. HEIGHT (IN CENTIMETERS) 10. WEIGHT (IN KILOGRAMS)
11. DISTINGUISHING FEATURE(S)

LEGALLY SEPARATED

(IF ANY)

PART IV - STATEMENT OF CONSENT
I declare that I am fully aware that the above data shall be used for securing my Common Reference Number (CRN) for the Unified MultiPurpose ID (UMID) System or updating my personal data in the CRN Registry. I trust that the above data shall remain confidential, hence, I give
my consent that the same data be secured and accessed for subsequent validation, verification and other purpose consistent with the objectives
of the UMID System under Executive Order No. (EO) 420 as amended by EO No. 700. I further affirm that all statements/data, which appear in
this application form and made by me are true, correct and complete to the best of my knowledge and belief.

PRINTED NAME

SIGNATURE

DATE

PART V - OTHER ENROLLEE DATA
TELEPHONE NUMBER (AREA CODE + TEL. NO.)

SS NUMBER

MOBILE/CELLPHONE NUMBER

E-MAIL ADDRESS

IF YOU ARE A SURVIVING SPOUSE/GUARDIAN/DEPENDENT OF DECEASED/PENSIONER MEMBER, PLEASE INDICATE SS NUMBER/COMMON REFERENCE
NUMBER (IF ANY) OF DECEASED/PENSIONER MEMBER BELOW
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
SS NUMBER/COMMON REFERENCE NUMBER
NAME OF MEMBER

PART VI - FOR SSS USE ONLY
IDENTIFICATION/DOCUMENT/S PRESENTED

REMARKS

SCREENED BY

DATA CAPTURED BY

DATE & TIME
SIGNATURE OVER PRINTED NAME
BRANCH
SIGNATURE OVER PRINTED NAME
DATE & TIME
-------------------------------------------------------------------------------------------------Perforate Here-------------------------------------------------------------------------------------------------

Republic of the Philippines

UNIFIED MULTI-PURPOSE ID (UMID) CARD APPLICATION FORM

ACKNOWLEDGEMENT STUB
SS NUMBER/COMMON REFERENCE NUMBER

NAME OF AGENCY

BRANCH

SOCIAL SECURITY SYSTEM
(LAST NAME)

NAME

(FIRST NAME)

SCREENED BY

SIGNATURE OVER PRINTED NAME

(MIDDLE NAME)

(SUFFIX)

DATA CAPTURED BY

DATE & TIME

SIGNATURE OVER PRINTED NAME

Perforate here

RIGHT THUMB

DATE & TIME

RIGHT INDEX

INSTRUCTIONS
1. This form shall be used in applying for initial or replacement UMID card.
2. Fill out this form in one (1) copy without erasures and alterations.
3. Place a checkmark on the applicable box.
4. Always indicate "N/A" or "Not Applicable", if the required data is not applicable.
5. Present identification document/s.
a. Any one (1) of the following primary documents:
▪ Driver's License
▪ Passport

▪ Professional Regulation Commission (PRC) card
▪ Seaman's Book

b. In the absence of the primary documents, submit any two (2) of the following secondary documents, one of which with signature and photo:
▪ Postal ID
▪ Marriage Contract
▪ School or Company ID
▪ NBI Clearance
▪ Taxpayer's Identification Number (TIN) card
▪ Pag-IBIG Member's Data Form
▪ Permit to Carry Firearms issued by the Firearms & Explosive Unit of PNP
▪ Membership Card issued by private companies
▪ Overseas Worker Welfare Administration Card
▪ PHIC Member's Data Record
▪ Senior Citizen Card
▪ Police Clearance
▪ Seafarer's Registration Certificate issued by the Philippine Overseas
▪ Voter's Identification Card/Affidavit/Certificate of Registration
Employment Authority (POEA)
▪ ATM card
▪ Temporary License issued by Land Transportation Office (LTO)
- with cardholder's name
- with certification from bank, if without name
▪ Transcript of School Records
▪ Credit card
▪ Alien Certificate of Registration
▪ Fisherman's Card issued by the Bureau of Fisheries and
▪ Bank Account Passbook
Aquatic Resources (BFAR)
▪ Certificate from:
- Office of the Southern/Northern Cultural Communities
▪ GSIS Card/Member's Record/Certificate of Membership
- Office of Muslim Affairs
▪ Health or Medical Card
▪ ID Card issued by LGUs (e.g. Barangay/ Municipal/City)
▪ Certificate of Licensure/Qualification Documents/Seafarer's ID & Record
Book from Maritime Industry Authority
▪ ID Card issued by professional association recognized by PRC
▪ Certificate of Naturalization from the Bureau of Immigration
▪ Permanent Residency ID
▪ Birth Certificate
▪ Life Insurance Policy
▪ Baptismal Certificate
▪ Birth/Baptismal certificate of child/ren or its equivalent
6. Fill out appropriate items in the following format:
a. Items 1, 5a and 5b
Example: Juan Andres Gregorio Toralba III will be entered as:

b. Item 1 (For Married Female)
Example: Anna Maria Dela Cruz Santos at birth and married name is Anna Maria Roman will be entered as:

c. Item 6
Example: 837 Akle St., Barangay Claro, Project 2, Quezon City 1102 will be entered as:

Indicate the permanent address rather than the temporary mailing address. For example, if with permanent residence in the province but
working or staying in Metro Manila during weekdays, indicate the provincial address instead of the Metro Manila address.
7. Write the "Height" in centimeters and "Weight" in kilograms.
To convert:
1 ft = 30.38 cm
1 lb = 0.4536 kg
1 in = 2.54 cm
8. In item 11, limit the distinguishing features to those that can be found on the face such as "mole under the right eye" and "mole or birth mark on the
left cheek/forehead".
9. For card replacement, pay the required fee at any SSS branch office/accredited bank/collecting agent and submit this form together with the required
document/s and validated Miscellaneous Payment Form or Special Bank Receipt (SBR) with Miscellaneous Payment Form to the nearest SSS branch
office.
10. For card replacement due to amendment of data/authenticating finger, submit the previously issued SSS or UMID card.
 
Page of
Share