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Get PH SSS PEN-01405 2019-2024

Republic of the Philippines SOCIAL SECURITY SYSTEM ANNUAL CONFIRMATION OF PENSIONER S FORM CERTIFIED BY SSS OFFICIAL/REGULAR EMPLOYEE Use black ink only in accomplishing this form 01-2012 PART I - MEMBER S / PENSIONER S DATA SS NUMBER OF MEMBER NAME OF MEMBER Surname Given Name Middle Name SS NUMBER OF PENSIONER NAME OF PENSIONER MAILING ADDRESS OF PENSIONER No* Street Barangay g y Town District TYPE OF PENSION/S Retirement City/Province y LANDLINE/ MOBILE NO. Postal Code SS Total Disability E- MAIL ADDRESS DATE OF BIRTH mm/dd/yyyy SS Death EC Death PART II - QUESTIONNAIRE 1. For 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 If yes name of spouse/partner Date of marriage/cohabitation 3. Are you under the care and custody of a guardian 4. Is there any dependent child who already got married employed or died If yes fill out the data below DATE OF NAME OF GUARDIAN GUARDIAN DATE OF MARRIAGE IF APPLICABLE EMPLOYMENT NAME OF DEPENDENT CHILDREN SS NO. DATE OF DEATH Ih hereby certify that the foregoing i f b tif th t th f i information i complete t ti is l t true and correct t th b t of my k d t to the best f knowledge. l d SIGNATURE OVER PRINTED NAME DATE 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 Below are the witnesses to fingerprinting PART III - CERTIFICATION OF SSS OFFICIAL/REGULAR EMPLOYEE For Retiree and Survivor Pensioners Left I certify that I have personal knowledge of existence of the subject pensioner because he is my . relationship Pensioner is living abroad unable to visit SSS incapacitated* DEPARTMENT/BRANCH POSITION EE ID NO. SSS OFFICIAL/REGULAR EMPLOYEE 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 . DETACH BELOW THIS LINE NOTICE OF SCHEDULE Please report for your Annual Confirmation anytime within the month of otherwise your pension will be suspended* ISSUED BY OF SSS PERSONNEL DESIGNATION For SSS Use Only PART IV - RECOMMENDATION Continue Suspend Reason Cancel Reason Re-adjudicate Reason Returned Reason Pending For further evaluation X-ray/ECG 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 RECOMMENDED BY APPROVED BY.

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