Republic of the Philippines SOCIAL SECURITY SYSTEM ANNUAL CONFIRMATION OF PENSIONERS PENSIONER'S REPLY BEN-01918 (04.2017) PLEASE READ THE ATTACHED INSTRUCTIONS BEFORE FILLING OUT THIS FORM, PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK INK ONLY. RT 1- TO BE FILLED OUT BY PENSIONER/IGUARDIAN, [TYPE OF PENSION DIRETIREMENT 99 TOTAL DISABILITY. CLEC TOTAL DISABILITY Diss oeah Dec pea 7A. DECEASED MEMBER INFORMATION (FOR DEATH PENSIONER) SSNONGER RANE TARTRATE TRSTRANE) “PADDLE NEY Ta PENSIONER INFORMATION. [GOWIMON REFERENCE NUMBER wan [DATE OF SIRTH wacom [SS NUMBER wear TAXPAYER 1D NUMBER ray Ett td dy Litititiitis ty LL fea ep ea ag (a Ha THODERATET SOFT [ADDRESS F CODE Ts the dependent (ninov/ncapaciiated) child under your care and custody aready maried, employediealt-ampioyed or deceased? D Yes (Fill out the applicable data) One Date of Merriage/Employment/Selt-EmploymentiDeath SS Number (if employedisetfemployed) 7 For retireectal disabilly ponsioner have you been r-employed/resumed seitemployment? Dyes CINe ifyes indicate the folowing Name and adress of present employer Date re-employed or resumed seltemployment 2. For survivor pensioner, have you been re-marrid oar you curerly cohabling wih another person? Cl Ves] No It yes, indicate name of spouselpartner Date of marriagelcohabitation For retireettal disabilityisurvivor pensioner, is/are there any dependent (minovincapactated) children under your care and custody? Yes (Fil-out tre applicable data below) DNo NAVE OF DEPENDENT DATE OF EMPLOYMENTISELF-EMPLOYMENT DATE OF (MINORIINGAPAGITATED) MARRIAGE DATE ‘SS NUMBER, DEATH Topublc ofthe Priippines ‘SOCIAL SECURITY SYSTEM ANNUAL CONFIRMATION OF PENSIONERS ACKNOWLEDGEMENT STUB & NOTICE OF SCHEDULE ISSNOJCONMON REFERENCE NO. (Faun JNAWE OF PENSIONER (51 NavEy ‘TST HAE) TUCOLE NAY Please report for your Annual Confirmation on Issueo ev N OT Otherwise, your pension will be suspended. TERT RB TERT TSIGHATURE OVER PRINTED NAME OF SSS/BANK PERSONNEL POSTION THLE. DATE STE| certity that the information provided in this form are true and correct. PRINTED NAVE OF PENSTONERIGUARDIAN SIGNATURE. —___DaTE If pensioner cannot sign, affix fingerprints. Please read instruction no. 5 in the attached Instructions for Annual Confrmation of Pensioners (Pensione’s Reply). Below are the witnesses to fingerprinting: 0 FOR PENSONER WHO CANNOT SGN —FRINTED aE ‘SIGNATURE, TE ADDRESS & CONTACT NUMBER. 2) | PRINTED NANE er DATE RIGHT THUME RIGHT INDEX [ADDRESS & CONTACT NUMBER PART Il- TO BE FILLED OUT BY THE BANK MANAGER (FOR RETIREE AND DEATH PENSIONERS COMPLYING WITH ACOP THROUGH THE BANK) Cee eee aa eee ee eee is to cenity that Mr./Mrs MIs a depositor of personally appeared before the undersigned on ‘as compliance with the Annual Confirmation of Pensioners (ACOP) Program being conducted by the Social Security System. PRINTED NAVE SIGNATURE, POSTION TITLE DATES TIME PART lll TO BE FILLED OUT BY SSS. (pore erEEOCcTC e A O COMPLIANCELT TOU ReCCL CE emcee EUS SSCL) Co PERSONAL Co Tru sank Co THRU REPRESENTATIVE CO THRU MAIL (THRU E-MAIL REMARKS La Identity of pensioner established 1 Deceased Pensioner others Di Fordata capture Date of Death, IL. For further interview INTERVIEWED ANDIOR SCREENED BY PRINTED NAVE SIGNATURE, POSTON TLE DATE STE 5, RECOMMENDATION i continue CiPending (For further evaluation) Di Suspend (Reason) D x-aylEC6 for reading Bi Cancel (Reason) G For Medical Fieldwork Services (MFS)Fact of Pensioners Existence (FPE) Di Re-adjudicate (Reason) 1D For referral to other BranctvUnit Gi Returned ACOP form (Reason) otters (Reason) [REVIEWED AND RECOMMENDED BY PRINTED NAVE SIGNATURE, POSTONTILE DATES TE [APPROVED BY PRINTED WANE STRATE, POSTON TITLE. DATE STE WARNING JANYONE WHO FALSIFIES ESSENTIAL INFORMATION REQUESTED BY THIS OR RELATED FORM MAY, UPON CONVICTION, BE SUBJECT TO FINE AND IMPRISONMENT UNDER THE LAW (SEC. 28 (a) OF THE SOCIAL SECURITY LAW| JAND ART. 207 (b) CHAPTER IX OF PD NO. 626.INSTRUCTIONS FOR ANNUAL CONFIRMATION OF PENSIONERS (PENSIONER'S REPLY) 1. All retirees, total disabiity pensioners, survivor pensioners, guardians and their dependent (minoriincapacitated) child/ren shall be required to report for the Annual Confirmation of Pensioners (ACOP) program, as follows: ‘Type of Pensioner_| Schedule of Compliance Where to Comply Retiree [Month of birth of the pensioner | » Member Services Section of any SSS branch office or 2 Depository bank Total Disabity [Month of bith ofthe pensioner | » Medical Evaluation Section of any SSS branch office Survivor Month of bith of te deceased | » Member Services Section of any SSS branch office or member service office; or «Depository bank Dependent IMonth of bith of the deceased | » Member Services Section of any SSS branch office or (irinovincapacitated) member service office; or (with their guardian) ‘© Depository bank . Fill out this form in one (1) copy. If receiving two (2) or more types of pension, fil out one (1) ACOP form for each type of pension. (eg. Ifthe pensioner is receiving both retirement and survivor pensions, the pensioner shall fil out two (2) ACOP forms). If guardian ‘of two (2) or more dependent (minor/incapacitated) children, fil out one (1) ACOP form for each dependent (minov/incapacitated) child ‘Always indicate "N/A" or "Not Applicable", if the required data is not applicable. ‘Write "Nothing Follows” immediately after the last dependent (minoriincapacitated) chi Ifthe pensioner cannot sign, witnesses to fingerprinting shall be as follows hen. (Item Part -D Table) * The SSS receiving personnel shall serve as witness who shall affix his/her signature on the portion provided for in Part LE Filed by Authorized Representative + Two (2) witnesses. One (1) witness is the pensioner’s authorized representative himself and the other one (1) could be any person. Both should afix their signatures and indicate their addresses and contact numbers on the portions provided for in Part LE. Filed through the Bank = The bank receiving personne! shall serve as witness who shall affix his/her signature on the portion provided for in Part LE The guardian of dependent (minorfincapacitated) children shall affix hisiher name and signature in Part IE For Pensioners Residing in the Philippines, present Social Security (SS) Card/Uniied Multi-purpose ID (UMID) Card/Passport or {wo (2) valid IDs, both with signature and at least one (1) with photo + If unable to report personally, submit photocopy of SS Card/UMID Card/Passport or two (2) valid IDs, both with signature and at least one (1) with photo and the following additional documents through the pensioner’s authorized representative or mail, whichever is applicable: To ioner * If confined at home - Sketch of residence of pensioner: or ¢ If confined in an institution - Certification from the institution where the pensioner is confined such as retirement home, penitentiary, nursing facility, hospital, correctional institution, rehabilitation center, etc Retiree, Survivor and Dependent (Minor/ineapacitated) Childiren, If confined at home ~ Sketch of residence of pensioner ~ Certification of pensioner’s existence from Barangay Chairman; and + Medical certificate on examination done within three (3) months of date of compliance and certified by a physician indicating his license number and clinic address. (e.g. if pensioner complied in June, medical cerificate on examination done should be within Apri, May and June) ‘If confined in an institution ~ Certication confirming pensioner’s confinement from the institution where the pensioner is confined such as retirement home, penitentiary, nursing facility, hospital, correctional institution, rehabilitation center, et. 8. For Pensioners Residing Abroad, submit the following documents through the pensioner's authorized representative at any Philippine/Foreign SSS representative office or mail addressed to the Branch Head, SSS Diliman Branch, East Avenue, Diliman, Quezon City, Philppines 1100 o e-mail at ofw.relations@sss.gov.ph * Photocopy of SS Card/UMID Card/Passport or two (2) valid IDs issued by the host county governmental uniVagency where photo ‘and signature are shown orin the absence of these, Certifeate of Appearance issued by the Philippine Embassy/Consulate; and * Additional documents, if applicable: ‘Total Disability Pensioner ‘+ Complete physical examination report done within three (3) months of date of compliance and certified by a physician indicating his license number and clinic address (e.g. if pensioner complied in June, medical certificate on examination done should be within Apri, May and June); and + Laboratory or other diagnostics examination results applicable to disabily 3 institution wi ps home, penitentiary, nursing facility, hospital, correctional institution, rehabilitation center, et. No