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Get Sss Sickness Form

FICATION PART I Date : (This Block to be accomplished by confined member. Please print all data.) SS Number: Name of Confined Member: Name of Employer: Residence: Address of Employer: Tax Account Number: Exact Date Confinement Started Place/Address of Confinement: This is to notify my employer that I am currently confined. The name of my employer, the place/address and the date when such confinement started are indicated above. I certify that I am hereby waiving in favor of the SSS all i.

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