"Annual Confirmation of Pensioner's Form" - Philippines

This "Annual Confirmation of Pensioner's Form" is a part of the paperwork released by the Philippine Social Security System specifically for Philippines residents.

The latest fillable version of the document was released on February 1, 2013 and can be downloaded through the link below or found through the department's forms library.

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Download "Annual Confirmation of Pensioner's Form" - Philippines

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Republic of the Philippines
SOCIAL SECURITY SYSTEM
ANNUAL CONFIRMATION OF PENSIONER'S FORM
PENSIONER'S REPLY
(02-2013)
THIS FORM IS NOT FOR SALE
PLEASE READ INSTRUCTIONS AND REMINDERS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS
AND USE BLACK INK ONLY.
PART I - MEMBER'S / PENSIONER'S INFORMATION
SS NUMBER OF PENSIONER
COMMON REFERENCE NO. (IF APPLICABLE)
DATE OF BIRTH (MMDDYYYY)
TIN
(IF SELF-EMPLOYED/EMPLOYED)
NAME
(SURNAME)
(GIVEN NAME)
(MIDDLE NAME)
(SUFFIX)
LOCAL ADDRESS
(
RM/FLR/ UNIT NO. & BLDG. NAME)
(HOUSE/LOT/& BLOCK NO.)
(STREET NAME)
(BARANGAY/DISTRICT/LOCALITY)
(SUBDIVISION)
(CITY/MUNICIPALITY)
(PROVINCE)
ZIP CODE
TELEPHONE NO. (AREA CODE + TEL. NO. ) MOBILE/CELLPHONE NO.
E-MAIL ADDRESS
FOREIGN ADDRESS
(IF APPLICABLE)
COUNTRY
ZIP CODE
TYPE/S OF PENSION/S BEING RECEIVED. CHECK THE APPROPRIATE BOX/ES.
SS Death
Retirement
SS Total Disability
EC Total Disability
EC Death
IF RECEIVING PENSION UNDER DEATH, INDICATE NAME/SS NO. OF DECEASED MEMBER
SS NO. OF DECEASED MEMBER
(SURNAME)
(GIVEN NAME)
(MIDDLE NAME)
(SUFFIX)
IF RECEIVING PENSION AS GUARDIAN, INDICATE NAME/SS NO. OF MEMBER
SS NO. OF MEMBER
(SURNAME)
(GIVEN NAME)
(MIDDLE NAME)
(SUFFIX)
PART II - QUESTIONNAIRE
1. For total disability/retirement pensioner, have you been re-employed/resumed self-employment ?
Yes
No
If yes, name and address of present employer :
Date re-employed or resumed self-employment :
2. For death pensioner, have you re-married or currently cohabiting with another person ?
Yes
No
If yes, name of spouse/partner:
Date of marriage/cohabitation:
3. Are you under the care and custody of a guardian?
Yes
No
If yes, name and address of guardian:
4. Is there any dependent child who already got married, employed or died ?
Yes
No
If yes, fill out the data below:
DATE OF
NAME OF GUARDIAN, IF
NAME OF DEPENDENT CHILDREN
DATE OF MARRIAGE
SS NO.
DATE OF DEATH
APPLICABLE
EMPLOYMENT
1
2
3
4
5
I hereby certify that the foregoing information is complete, true and correct to the best of my knowledge.
SIGNATURE OVER PRINTED NAME
DATE
OF PENSIONER
RIGHT THUMB
RIGHT INDEX
(If unable to sign, affix fingerprints with the signature of two witnesses and
submit photocopy of one valid ID with photo and signature of each witness)
Witnesses to fingerprints:
1)
2)
SIGNATURE OVER PRINTED NAME
DATE
SIGNATURE OVER PRINTED NAME
DATE
Left
PART III - CERTIFICATION OF BANK MANAGER/BARANGAY CHAIRMAN
(For Retiree and Survivor Pensioners)
Check the appropriate box (one only):
Bank Manager
Barangay Chairman
This
is
to
certify
that
Mr./Ms._____________________________________________,
a
depositor/bonafide
resident
of
__________________________________________________________________ personally appeared before the undersigned on ___________________________ as
compliance to the annual confirmation of pensioners being conducted by the Social Security System.
SIGNATURE OVER PRINTED NAME
DATE
NOTICE: Anyone who falsifies essential information requested by this or a related form may, upon conviction, be subject to fine and imprisonment under the
law (Sec. 28 (a) of the Social Security Law and Art.207 (b) Chapter IX of PD # 626).
Republic of the Philippines
SOCIAL SECURITY SYSTEM
ANNUAL CONFIRMATION OF PENSIONER'S FORM
PENSIONER'S REPLY
(02-2013)
THIS FORM IS NOT FOR SALE
PLEASE READ INSTRUCTIONS AND REMINDERS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS
AND USE BLACK INK ONLY.
PART I - MEMBER'S / PENSIONER'S INFORMATION
SS NUMBER OF PENSIONER
COMMON REFERENCE NO. (IF APPLICABLE)
DATE OF BIRTH (MMDDYYYY)
TIN
(IF SELF-EMPLOYED/EMPLOYED)
NAME
(SURNAME)
(GIVEN NAME)
(MIDDLE NAME)
(SUFFIX)
LOCAL ADDRESS
(
RM/FLR/ UNIT NO. & BLDG. NAME)
(HOUSE/LOT/& BLOCK NO.)
(STREET NAME)
(BARANGAY/DISTRICT/LOCALITY)
(SUBDIVISION)
(CITY/MUNICIPALITY)
(PROVINCE)
ZIP CODE
TELEPHONE NO. (AREA CODE + TEL. NO. ) MOBILE/CELLPHONE NO.
E-MAIL ADDRESS
FOREIGN ADDRESS
(IF APPLICABLE)
COUNTRY
ZIP CODE
TYPE/S OF PENSION/S BEING RECEIVED. CHECK THE APPROPRIATE BOX/ES.
SS Death
Retirement
SS Total Disability
EC Total Disability
EC Death
IF RECEIVING PENSION UNDER DEATH, INDICATE NAME/SS NO. OF DECEASED MEMBER
SS NO. OF DECEASED MEMBER
(SURNAME)
(GIVEN NAME)
(MIDDLE NAME)
(SUFFIX)
IF RECEIVING PENSION AS GUARDIAN, INDICATE NAME/SS NO. OF MEMBER
SS NO. OF MEMBER
(SURNAME)
(GIVEN NAME)
(MIDDLE NAME)
(SUFFIX)
PART II - QUESTIONNAIRE
1. For total disability/retirement pensioner, have you been re-employed/resumed self-employment ?
Yes
No
If yes, name and address of present employer :
Date re-employed or resumed self-employment :
2. For death pensioner, have you re-married or currently cohabiting with another person ?
Yes
No
If yes, name of spouse/partner:
Date of marriage/cohabitation:
3. Are you under the care and custody of a guardian?
Yes
No
If yes, name and address of guardian:
4. Is there any dependent child who already got married, employed or died ?
Yes
No
If yes, fill out the data below:
DATE OF
NAME OF GUARDIAN, IF
NAME OF DEPENDENT CHILDREN
DATE OF MARRIAGE
SS NO.
DATE OF DEATH
APPLICABLE
EMPLOYMENT
1
2
3
4
5
I hereby certify that the foregoing information is complete, true and correct to the best of my knowledge.
SIGNATURE OVER PRINTED NAME
DATE
OF PENSIONER
RIGHT THUMB
RIGHT INDEX
(If unable to sign, affix fingerprints with the signature of two witnesses and
submit photocopy of one valid ID with photo and signature of each witness)
Witnesses to fingerprints:
1)
2)
SIGNATURE OVER PRINTED NAME
DATE
SIGNATURE OVER PRINTED NAME
DATE
Left
PART III - CERTIFICATION OF BANK MANAGER/BARANGAY CHAIRMAN
(For Retiree and Survivor Pensioners)
Check the appropriate box (one only):
Bank Manager
Barangay Chairman
This
is
to
certify
that
Mr./Ms._____________________________________________,
a
depositor/bonafide
resident
of
__________________________________________________________________ personally appeared before the undersigned on ___________________________ as
compliance to the annual confirmation of pensioners being conducted by the Social Security System.
SIGNATURE OVER PRINTED NAME
DATE
NOTICE: Anyone who falsifies essential information requested by this or a related form may, upon conviction, be subject to fine and imprisonment under the
law (Sec. 28 (a) of the Social Security Law and Art.207 (b) Chapter IX of PD # 626).
For SSS Use Only
PART IV - DOCUMENTS SUBMITTED
Type of Compliance :
Personal
Thru Bank
Thru Representative
Thru Mail
Abroad
Incapacitated
Barangay Official
Institution
PENSIONER IS LIVING ABROAD
PENSIONER IS A LOCAL RESIDENT
Signed letter
Signed letter
Accomplished ACOP Form
Accomplished ACOP Form
Photocopy of valid passport
Sketch of residence
Photocopy of SS Card
Certification from
Photocopy of valid ID issued by host country governmental unit/
Barangay
agency (Pls. specify)
Institution
Photocopy of two (2) valid IDs (Pls. Specify)
Bank
1)
Medical Certificate
2)
Death Certificate
Medical Certificate
Complete physical examination report
Death Certificate
Relevant laboratory or diagnostic result
Complete physical examination report
SS Card
Relevant laboratory or other diagnostic exam results
Two (2) valid IDs (Pls. specify)
1)_______________________
Certification issued by (Pls. specify)
2)_______________________
ACTION TAKEN/REMARKS
Identity of pensioner established
For data capture
For interview (Lacks valid IDs for the issuance of SS No./Data Capture, etc.)
Deceased Pensioner
(Date of Death)
Others ________________________________________________
INTERVIEWED & SCREENED BY
SIGNATURE OVER PRINTED NAME
DESIGNATION
DATE
PART V - RECOMMENDATION
Continue
Suspend (Reason)___________________________________________________________________________________________
Cancel (Reason) ____________________________________________________________________________________________
Re-adjudicate (Reason) _______________________________________________________________________________________
Returned (Reason) __________________________________________________________________________________________
Pending (For further evaluation)
X-ray/ECG for reading
For Medical Fieldwork Services (MFS)
For Fact of Pensioner's Existence (FPE)
For referral to other branch/unit
Others
REVIEWED &/OR RECOMMENDED BY
SIGNATURE OVER PRINTED NAME
DESIGNATION
DATE
APPROVED BY
SIGNATURE OVER PRINTED NAME
DESIGNATION
DATE
This is your guide to accomplish the
ACOP Form
For Retiree or
Total Disability
Pensioner, fill
1
out no. 1
For Survivor
Pensioner, fill
For Pensioner
out nos. 1 & 2
under a
Guardian, fill out
nos. 1 & 3
2
3
ACKNOWLEDGEMENT RECEIPT
SS NUMBER OF PENSIONER
NAME OF PENSIONER
(SURNAME)
(GIVEN NAME)
(MIDDLE NAME) (SUFFIX)
SS NUMBER OF MEMBER
NAME OF MEMBER
(SURNAME)
(GIVEN NAME)
(MIDDLE NAME) (SUFFIX)
Please report for your Annual Confirmation anytime within your or member's birth month ; otherwise your pension will be suspended.
ISSUED BY:
DESIGNATION
DATE
SIGNATURE OVER PRINTED NAME
OF SSS /BANK PERSONNEL
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