Pensioner's Data Change Request

SSS form used to change pensioner's data

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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