Social Security System Death Claim Application
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3Republic of the Philippines
SOCIAL SECURITY SYSTEM
DEATH CLAIM APPLICATION
(04-2012)
PART I
Please read the instructions at the back of the form before filling-up the application. Print information in capital letters and use black ink only.
MEMBER'S INFORMATION
SS NUMBER
NAME OF MEMBER
Surname)
(Given Name)
(Middle Name
(
)
DATE OF BIRTH
DATE OF DEATH
PLACE OF DEATH
(mm-dd-yyyy)
(mm-dd-yyyy)
(Town/District) (City/Province)
TYPE OF CLAIM
CIVIL STATUS
Social Security
Employees’ Compensation
Single
Married
Legally Separated
Widow/Widower
EMPLOYMENT HISTORY
(Use separate sheet, if necessary)
PERIOD OF EMPLOYMENT (mm-yyyy)
NAME OF EMPLOYER
ADDRESS
From
To
1.
2.
3.
4.
DEPENDENT CHILDREN
(Below 21 years old or above 21 but incapacitated)
CHECK APPLICABLE
DATE OF BIRTH
COLUMN
NAME OF CHILDREN
ADDRESS
(mm-dd-yyyy)
Legitimate
Illegitimate
1.
2.
3.
4.
5.
CLAIMANT'S INFORMATION
SS NUMBER
NAME OF CLAIMANT
(If any)
(Surname)
(Given Name)
(Middle Name)
POSTAL CODE
ADDRESS
(Number, Street and Subdivision)
(Barangay)
(Town/District)
(City/Province)
DATE OF BIRTH
GENDER
RELATIONSHIP TO MEMBER
(mm-dd-yyyy)
Male
Female
TIN
TELEPHONE (Including Area Code) / MOBILE NO.
PREFERRED MODE OF PAYMENT
Cash Card
ATM/Passbook
PERFORATE HERE
RECEIVED BY:
SOCIAL SECURITY SYSTEM
DEATH CLAIM APPLICATION
ACKNOWLEDGMENT STUB
SIGNATURE OVER PRINTED NAME
DATE
(04-2012)
PLEASE PRESENT THIS WHEN INQUIRING ABOUT THE STATUS OF YOUR APPLICATION. VERIFICATION
WILL BE ENTERTAINED AFTER _____ DAYS FROM THE DATE OF RECEIPT. YOU MAY VERIFY THRU
SSS WEBSITE AT
RECEIVING BRANCH
SS NUMBER
NAME OF MEMBER
(Surname)
(Given Name)
(M.I.)
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