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Death Claim Application Form
SSS application form for Death Claim
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
SOCIAL SECURITY SYSTEM
DEATH CLAIM APPLICATION
(04-2012)
PART I
Please read the instructions at the back of the form before filling-up the application. Print information in capital letters and use black ink only.
MEMBER'S INFORMATION
NAME OF MEMBER (Surname)
SS NUMBER
DATE OF BIRTH (mm-dd-yyyy)
DATE OF DEATH (mm-dd-yyyy)
TYPE OF CLAIM
Social Security
(Given Name)
(Middle Name)
PLACE OF DEATH (Town/District) (City/Province)
CIVIL STATUS
Employees’ Compensation
Single
Married
Legally Separated
Widow/Widower
EMPLOYMENT HISTORY (Use separate sheet, if necessary)
NAME OF EMPLOYER
PERIOD OF EMPLOYMENT (mm-yyyy)
From
To
ADDRESS
1.
2.
3.
4.
DEPENDENT CHILDREN (Below 21 years old or above 21 but incapacitated)
CHECK APPLICABLE
DATE OF BIRTH
COLUMN
NAME OF CHILDREN
Legitimate
(mm-dd-yyyy)
Illegitimate
ADDRESS
1.
2.
3.
4.
5.
CLAIMANT'S INFORMATION
NAME OF CLAIMANT (Surname)
SS NUMBER (If any)
ADDRESS (Number, Street and Subdivision)
DATE OF BIRTH (mm-dd-yyyy)
(Barangay)
(Town/District)
GENDER
Male
(Given Name)
POSTAL CODE
(City/Province)
RELATIONSHIP TO MEMBER
Female
TELEPHONE (Including Area Code) / MOBILE NO.
TIN
(Middle Name)
PREFERRED MODE OF PAYMENT
Cash Card
ATM/Passbook
PERFORATE HERE
RECEIVED BY:
SOCIAL SECURITY SYSTEM
DEATH CLAIM APPLICATION
ACKNOWLEDGMENT STUB
SIGNATURE OVER PRINTED NAME
(04-2012)
DATE
PLEASE PRESENT THIS WHEN INQUIRING ABOUT THE STATUS OF YOUR APPLICATION. VERIFICATION
WILL BE ENTERTAINED AFTER _____ DAYS FROM THE DATE OF RECEIPT. YOU MAY VERIFY THRU
SSS WEBSITE AT www.sss.gov.ph.
RECEIVING BRANCH
SS NUMBER
NAME OF MEMBER
(Surname)
(Given Name)
(M.I.)
INSTRUCTIONS
1. Accomplish Parts I and II of this form in one (1) copy without erasures or alterations.
2. Support date of birth, marriage or death with birth/baptismal certificate, marriage contract or death
certificate (original duplicate/certified true copy/certified photocopy) duly registered with the National
Statistics Office/ Local Civil Registrar Office/Parish/Church. The baptismal certificate may be submitted in
lieu of birth certificate. For member who died abroad, death certificate should be duly registered with the
Vital Statistics Office of the country where the member died.
3. Present original and submit photocopy of single savings account passbook/ATM card with name and
copy of bank validated deposit slip or Cash Card Enrollment Form.
4. Attach your recent 1 x 1 photo.
5. Affix your fingerprints (right thumb and right index) on the portions provided for in the application form in
the presence of an SSS employee. In case the claimant could not sign, fingerprints should be witnessed
by two (2) persons, at least one (1) of whom is an SSS employee.
6. Present Social Security Card or SS Form E-6 Acknowledgment Stub with 2 valid IDs, at least one (1) with
photo.
7. Present original and submit photocopy of identification cards.
8. Write "N/A" for items not applicable and/or delete portion/s not applicable in the Certification.
WARNING
ANY PERSON WHO MAKES ANY FALSE STATEMENT IN THIS APPLICATION OR
SUBMITS ANY FALSIFIED DOCUMENT IN CONNECTION WITH THIS CLAIM SHALL BE
LIABLE CRIMINALLY FOR FALSIFICATION OF PUBLIC DOCUMENTS (SECTION 28 OF
R.A. 8282)
NOTES:
1. RE-COMPUTATION OR ADJUSTMENT AND FILING OF PETITION ASSAILING SETTLED
CLAIMS SHALL NOT BE ALLOWED AFTER TEN (10) YEARS FROM THE DATE OF INITIAL
SETTLEMENT OF CLAIM.
2. A PERSON WHO CONTINUOUSLY RECEIVES MONTHLY PENSION DESPITE OF REMARRIAGE OR COHABITATION SHALL BE CRIMINALLY LIABLE UNDER RA 8282 (Social
Security Act of 1997).
PART II
ARE YOU CURRENTLY RECEIVING SSS PENSION?
Yes
IF YES, CHECK TYPE OF PENSION
No
Disability
Retirement
Death
IF RECEIVING PENSION UNDER DEATH, INDICATE SS NUMBER AND NAME OF DECEASED MEMBER:
SS NUMBER
NAME OF MEMBER (Surname)
(Given Name)
(Middle Name)
BRSTN (For SSS Use Only)
NAME OF BANK/BRANCH
BANK ADDRESS
SAVINGS ACCOUNT NUMBER
CERTIFICATION
I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT, AND IF
APPLICABLE, THAT:
1. The aforementioned children are under my care and custody;
2. I am competent to receive in behalf of the said children the amount due them as dependents
of the subject member of the SSS;
3. I have not abandoned, neglected, refused to support said children, nor caused them to commit
offenses against the law;
4. None of the aforementioned children are married nor employed; and
5. I will immediately notify the SSS in case any of the above listed children die, marry or become
employed, or I cohabit or remarry.
SIGNATURE OF CLAIMANT
DATE
(If claimant cannot sign, fingerprints should be witnessed by two persons)
WITNESSES TO FINGERPRINTS
Please affix signature over printed name and indicate date
1.
Right Thumb
2.
Right Index
FOR SSS USE
FINDINGS:
No other pending claim
SCREENED BY:
RECEIVED BY:
Others (specify)
SIGNATURE OVER PRINTED NAME
DATE
SIGNATURE OVER PRINTED NAME
DATE
