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Pensioner's Data Change Request
SSS form used to change pensioner's data
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
SOCIAL SECURITY SYSTEM
PENSIONER'S DATA CHANGE REQUEST
(Please read instructions at the back. Print all information in capital letters & use black ink only)
SS NUMBER:
NAME OF MEMBER:
(SURNAME)
(GIVEN NAME)
(MIDDLE NAME)
1. CORRECTION OF NAME OF BENEFICIARY
FROM __________________________________________________________
TO _____________________________________________________________
2. CHANGE OF ADDRESS
(Number & Street) (Barangay) (Town/District) (City/Province) (Postal Code)
FROM __________________________________________________________
TO _____________________________________________________________
3. CHANGE OF ACCOUNT NUMBER/BANK
FROM __________________________________________________________
TO _____________________________________________________________
4. EXEMPTION FROM MAG-IMPOK SA BANGKO PROGRAM
REASON _________________________________________________________________________________________________________________________
SIGNATURE OF CLAIMANT
Signature Over Printed Name
Date
WITNESSES TO THUMBMARK (If member/claimant cannot sign)
1. __________________________________________________________
Signature Over Printed Name
Date
2. __________________________________________________________
Date
Signature Over Printed Name
Right Thumbmark
Left Index
FOR SSS USE
RECEIVED:
Signature over Printed Name/Date
PROCESSED:
Signature over Printed Name/Date
APPROVED:
Signature over Printed Name/Date
ENCODED:
Signature over Printed Name/Date
INSTRUCTIONS
1. Accomplish this form in one (1) copy.
2. Submit the following required documents for the following changes:
Correction of Name of Beneficiaries
Birth/Baptismal Certificate or in the absence of both, any two (2) of the secondary
documents enumerated below; and Affidavit of two (2) persons who have personal
knowledge of the fact that the name appearing in the primary/secondary documents
belongs to the same person.
Documents that may be submitted in the absence of primary documents:
- Record of Employment (accomplished upon employment)
- GSIS Member's Record (if member is also a gov't. employee)
- Certification from the National Archives
- Alien Certificate of Registrations (ACR)
- Marriage Contract of member
- Birth Certificate of children
- School records
- Passport
- Joint Affidavit of two (2) disinterested persons attesting to the fact of your birth
Change of Address
• Latest check voucher
Exemption from Mag-Impok sa Bangko Program
• Letter request
Change of Account Number/Bank
• Old and new passbook
