Republic of the Philippines
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E-1 |
SOCIAL SECURITY SYSTEM |
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PERSONAL RECORD |
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COV-01214 (09-2015) |
FOR ISSUANCE OF SS NUMBER |
THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE. THIS CAN ALSO BE DOWNLOADED THRU THE SSS WEBSITE AT www.sss.gov.ph.
PLEASE READ THE INSTRUCTIONS AND REMINDERS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND
USE BLACK INK ONLY.
PART I - TO BE FILLED OUT BY THE REGISTRANT
A. PERSONAL DATA
NAME |
(LAST NAME) |
(FIRST NAME) |
(MIDDLE NAME) |
(SUFFIX) |
DATE OF BIRTH (MMDDYYYY) |
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SEX |
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CIVIL STATUS |
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TAX IDENTIFICATION NUMBER (IF ANY) |
Male |
Female |
Single |
Married |
Widowed |
Legally Separated |
Others ________________ |
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NATIONALITY |
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RELIGION |
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PLACE OF BIRTH (CITY/MUNICIPALITY, PROVINCE) (CITY, COUNTRY, if born outside the Philippines) |
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HOME ADDRESS |
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(RM./FLR./UNIT NO. & BLDG. NAME) |
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(HOUSE/LOT & BLK. NO.) |
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(STREET NAME) |
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(SUBDIVISION) |
(BARANGAY/DISTRICT/LOCALITY) |
(CITY/MUNICIPALITY) |
(PROVINCE) |
(COUNTRY) |
TELEPHONE NUMBER (COUNTRY CODE+ AREA CODE+ TEL. NO.)
FATHER |
(LAST NAME) |
(FIRST NAME) |
(MIDDLE NAME) |
(SUFFIX) |
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MOTHER'S MAIDEN NAME |
(LAST NAME) |
(FIRST NAME) |
(MIDDLE NAME) |
(SUFFIX) |
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B. DEPENDENT(S)/BENEFICIARY/IES |
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Check this box if using additional sheet. |
SPOUSE |
(LAST NAME) |
(FIRST NAME) |
(MIDDLE NAME) |
(SUFFIX) |
DATE OF BIRTH (MMDDYYYY) |
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CHILD/REN |
(LAST NAME) |
(FIRST NAME) |
(MIDDLE NAME) |
(SUFFIX) |
DATE OF BIRTH (MMDDYYYY) |
1. |
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2. |
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3. |
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4. |
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5. |
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OTHER BENEFICIARY/IES (If without spouse & child and parents are both deceased) |
RELATIONSHIP |
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DATE OF BIRTH (MMDDYYYY) |
(LAST NAME) |
(FIRST NAME) |
(MIDDLE NAME) |
(SUFFIX) |
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1. |
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2.
C. FOR SELF-EMPLOYED/OVERSEAS FILIPINO WORKER/NON-WORKING SPOUSE
SELF-EMPLOYED (SE)
Profession/Business
Year Prof./Business Started
Monthly Earnings
P
OVERSEAS FILIPINO WORKER (OFW)
Foreign Address
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Are you applying for membership |
Monthly Earnings |
in the Flexi-Fund Program? |
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P |
YES |
NO |
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NON-WORKING SPOUSE (NWS)
SS No./Common Reference No. of Working Spouse
Monthly Income of Working Spouse (P)
I agree with my spouse's membership with SSS.
SIGNATURE OVER PRINTED NAME OF WORKING SPOUSE
I certify that the information provided in this form are true and correct.
(If registrant cannot sign, affix fingerprints in the presence of an SSS personnel.)
Registrant is required to affix fingerprints.
PRINTED NAME |
SIGNATURE |
DATE |
PART II - TO BE FILLED OUT BY SSS
BUSINESS CODE |
WORKING SPOUSE's MSC (FOR |
(FOR SE) |
NWS) |
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P |
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MONTHLY SS CONTRIBUTION |
APPROVED MSC |
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(FOR SE/OFW/NWS) |
(FOR SE/OFW/NWS) |
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P |
P |
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START OF PAYMENT |
FLEXI-FUND APPLICATION |
(FOR SE/NWS) |
(FOR OFW) |
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Approved |
Disapproved |
RECEIVED BY |
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RECEIVED & PROCESSED BY |
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(REPRESENTATIVE OFFICE/PARTNER AGENT) |
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(MSS, BRANCH/SERVICEOFFICE/FOREIGN OFFICE) |
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SIGNATURE OVER PRINTED NAME |
DATE & TIME |
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SIGNATURE OVER PRINTED NAME |
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DATE & TIME |
REVIEWED BY |
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(MSS, BRANCH/SERVICE OFFICE) |
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SIGNATURE OVER PRINTED NAME |
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DATE & TIME |
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INSTRUCTIONS
1.Fill out this form and submit to the nearest SSS branch office together with the required documents.
2.Fill out the applicable portions as follows:
Parts I-A, B and D, if applying for SS number as pre-employment requirement
Parts I-A, B, C and D, if applying for Self-Employed, Overseas Filipino Worker (OFW) or Non-Working Spouse membership
-For Part I-B "DEPENDENT(S)/BENEFICIARY/IES", use "Additional Sheet for Dependent(s)/Beneficiary/(ies)", if necessary.
3.Always indicate "N/A" or "Not Applicable", if the required data is not applicable.
4.If this form is to be downloaded from the internet, please fill-out in two (2) copies.
REMINDERS
1.New registrant who is over sixty (60) years old and not a surviving spouse pensioner/guardian of a pensioner, is not qualified to apply for an SS number.
2.Your SS number is your lifetime number. You should not have more than one SS number.
3.The following required documents should be the original or certified true copy issued by the City or Municipal Civil Registrar or Philippine Statistics Authority/National Statistics Office:
3.1Birth Certificate
3.2Marriage Contract/Marriage Certificate
3.3Death Certificate
4.All identification (ID) cards and/or documents with English translation issued by foreign government are acceptable.
LIST OF DOCUMENTARY REQUIREMENTS
Always present the original or certified true copy/ies when submitting the photocopy/ies of the required ID card(s) and/or document(s).
A. |
ID Cards and/or Documents for the Issuance of SS Number |
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Marriage Contract/Marriage Certificate |
Birth Certificate, or in its absence, any of the following |
National Bureau of Investigation (NBI) Clearance |
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documents: |
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Overseas Worker Welfare Administration (OWWA) card |
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Baptismal Certificate or its equivalent |
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Philippine Health Insurance Corporation (PHIC) ID |
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Driver's License |
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card/Member's Data Record |
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Passport |
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Police Clearance |
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Professional Regulation Commission (PRC) card |
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Postal ID card |
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Seaman's Book (Seafarer's Identification and Record Book) |
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School ID card |
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Seafarer's Registration Certificate issued by Philippine |
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In the absence of the above ID cards and/or documents, any two |
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Overseas Employment Administration (POEA) |
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(2) of the following documents both with the correct name and at |
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Senior Citizen card |
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least one (1) with date of birth: |
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Student Permit issued by Land Transportation Office (LTO) |
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Alien Certificate of Registration |
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Taxpayer's Identification Number (TIN) card |
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ATM card (with cardholder's name) |
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Transcript of Records |
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Bank Account Passbook |
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Voter's ID card/Affidavit/Certificate of Registration |
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Baptismal Certificate of child/ren or its equivalent |
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B. Additional Supporting Documents |
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Birth Certificate of child/ren |
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For married |
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Certificate of Confirmation issued by National Commission on |
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Marriage Contract/Marriage Certificate or a copy of |
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Indigenous Peoples (formerly Office of Southern Cultural |
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Member Data Change Request form (SS Form E-4) |
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Community and Office of Northern Cultural Community) |
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of the spouse duly received by the SSS where the |
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Certificate of Licensure/Qualification Documents from Maritime |
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name of the |
registrant is reported as the spouse |
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Industry Authority |
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For widowed |
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Certificate of Muslim Filipino Tribal Affiliation issued by |
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Marriage Contract/Marriage Certificate |
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National Commission on Muslim Filipinos |
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Marriage Contract/Marriage Certificate and Death |
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Company ID card |
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Certificate of spouse or Court Order on the |
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Court Order granting petition for change of name or date of |
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Declaration of Presumptive Death, if previously |
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birth |
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reported spouse is presumed dead |
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Credit card |
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For legally separated |
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Firearm License card issued |
by Philippine |
National |
Police |
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Decree of Legal Separation |
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(PNP) |
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For annulled or with void marriage |
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Fishworker's License issued by Bureau of Fisheries and |
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Certificate |
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of Finality of Annulment/Nullity or |
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Aquatic Resources (BFAR) |
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annotated |
Marriage Contract/Marriage Certificate |
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Government Service Insurance System (GSIS) card/ |
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For divorced |
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Member's Record/Certificate of Membership |
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Decree of Divorce and Certificate of Naturalization |
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Health or Medical card |
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(granted before divorce) or its equivalent |
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Home Development Mutual Fund (Pag-IBIG) Transaction |
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For divorced Muslim member |
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card/Member's Data Form |
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Certificate of Divorce (OCRG Form No. 102) |
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Homeowners Association ID card |
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For reporting child/ren |
- whichever is applicable |
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ID card issued by Local |
Government |
Units |
(LGUs) |
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Birth Certificate/s or Baptismal Certificate/s or its |
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(e.g., Barangay/ Municipality/ City) |
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equivalent |
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ID card issued by professional association recognized by |
C. |
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Decree of Adoption |
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PRC |
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Documents for local enrolment in the Flexi-fund Program |
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Valid‒ |
Overseas Employment Certificate (OEC) or E- |
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Life Insurance Policy |
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receipt issued by POEA |