Republic of the

Philippines
SOCIAL SECURITY SYSTEM
E-4 MEMBER DATA CHANGE REQUEST
COV-01215 (09-2015)

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 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 MEMBER

A. PERSONAL DATA
SS NUMBER COMMON REFERENCE NUMBER (IF ANY) DATE OF BIRTH (MMDDYYYY) TAX IDENTIFICATION NUMBER (IF ANY)

NAME (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)

ADDRESS (RM./FLR./UNIT NO. & BLDG. NAME) (HOUSE/LOT & BLK NO.) (STREET NAME)

(SUBDIVISION) (BARANGAY/DISTRICT/LOCALITY) (CITY/MUNICIPALITY) (PROVINCE) ZIP CODE

TELEPHONE NUMBER (AREA CODE + TEL. NO.) MOBILE/CELLPHONE NUMBER E-MAIL ADDRESS

FOREIGN ADDRESS (IF APPLICABLE) COUNTRY ZIP CODE

B. DATA CHANGE/CORRECTION/UPDATING
A.
CHANGE OF MEMBERSHIP TYPE
FROM
Employed
Voluntary
Overseas Filipino Worker
Non-Working Spouse (NWS)
Prior Registrant
(A person who registered with the SSS for the first time as a prospective employee. )

B.
CORRECTION OF NAME
 TO TO (Option for Prior Registrant Only)
Self-Employed (Please fill-out the details below.) Non-Working Spouse (Please fill-out the details below.)
Profession/Business SS No./CRN of Working Spouse

Year Profession/Business Started Monthly Income of Working Spouse (P)

Monthly Earnings (P) I AGREE WITH MY SPOUSE'S MEMBERSHIP WITH SSS.

SIGNATURE OVER PRINTED NAME OF WORKING SPOUSE

FROM TO
Last Name First Name Middle Name
(or change of middle initial to middle name)
Re G. UPDATING OF BANK
Prefix (e.g., "de", "dela", "delos", INFORMATION
"del", "Ma." or "Maria") or Suffix ver E-mail
sio Bank Name Address
(e.g., Jr., II or III)
n
Simple Error in Spelling of Name fro Benefits (Sickness/
(e.g., "i" to "e" or "u" to "o" or vice m Maternity/Partial
Bank Branch
versa; inclusion/ deletion of space Ma Disability)
M
and special characters) rrie ob
d Loans
ile
3. Due to to Re-marriage to /C
CORRECTION OF DATE OF BIRTH PESO Fund
Sin ell
4. gle ph
CORRECTION OF SEX
on
5. CHANGE OF CIVIL STATUS F. e
UPDATI N
(For Female members: Accomplish the NG OF u
FROM and TO portions, if also m
requesting for change of name) CONTAC
be
T r
Single to Married INFORM
ATION
Married to Legally Separated
Address Accou
Married to Widowed
Numbe
r DENT(S)/BENEFICI
ARY(IES) (Please
8. m
check the
a
appropriate box. If
n more than 3, use
U
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 NAME (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX) RELATIONSHIP TO MEMBER DATE OF BIRTH (MMDDYYYY)
New/Additional
1. Deletion
New/Additional
2. Deletion
New/Additional
3. Deletion
Pag e 1 of 2
 REMINDERS

1. 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:
1.1Birth Certificate
1.2Marriage Contract/Marriage Certificate
1.3Death Certificate
2. All ID cards and/or documents with English translation issued by foreign governments 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).

1. Change of membership type

1. To Self-Employed - No required documents

2. To Non-Working Spouse - Marriage Contract/Marriage Certificate or a copy of Working Spouse's Member Data Change Request form (SS
Form E-4) duly received by the SSS where the name of the NWS is indicated as the spouse

B./C. Correction of name and/or Correction of date of birth

1. Birth Certificate or Passport.

2. In the absence of the Birth Certificate and Passport, the following are the required ID cards and/or documents:
1. Certificate of Non-Availability of Birth Records from the City or Municipal Civil Registrar or Philippine Statistics Authority/National
Statistics Office or National Archives, for the alleged correct name/date of birth; and
2. Any TWO (2) of the following, both with the correct name and at least one (1) with date of birth:
Documents Record/Certificate of
ID Cards Membership

1 Alien Certificate of 8 Life Insurance Policy

1 Driver's License Registration 9 Marriage
2 Firearm License Card issued by Philippine National Police 2 Baptismal Certificate or Contract/Marriage Certificate

3 Government Service Insurance System (GSIS) ID Card its equivalent (member's) 10 National Bureau of
3 Birth Investigation (NBI) Clearance
4 Health or Medical Card
Certificate/Baptismal 11 Pag-IBIG Member's Data
5 Home Development Mutual Fund (Pag-IBIG) Transaction Card Certificate or its equivalent Form
(child/ren's)
6 ID Card issued by Local Government Units (LGUs) (e.g., 12 PHIC Member's Data
Barangay/Municipality/City) 4 Certificate of Record
Licensure/Qualification 13
7 Overseas Worker Welfare Administration (OWWA) Card Documents from Maritime Police Clearance
Industry Authority 14
8 Philippine Health Insurance Corporation (PHIC) ID Card Seaman's Book
9 Postal ID Card 5 Certificate of Muslim (Seafarer's Identification and
Filipino Tribal Affiliation Record book)
10 Professional Regulation Commission (PRC) Card issued by
Commission on Muslim
National 15 Student Permit issued by
11 Senior Citizen Card Filipinos Land Transportation Office
(LTO)
12 Taxpayer's Identification Number (TIN) Card 6 Court Order granting
petition for change of name 16 Transcript of Records
13 Voter's Identification Card or date of birth 17 Voter's
7 GSIS Member's Affidavit/Certificate of
Registration
for the following 1. If for and submitted birth certificate is registered
cases: after the 55th birthday - two (2) ID cards
3. Required additional ID cards and/or documents correction of
and/or documents in Item 2.b above.
date of birth
personal totally name (except if due to and ces on the use of the different
different naturalization) - Joint Affidavit of two circu name/middle name stating
2. If for correction to who have name/middle (2) persons knowledge of the facts mstan therein that the two
(2) names refer to pi I ate Driver's e, if due to
one (1) and the C n d issued by License) death of
same person and ert e e the previously
the reason why ifi D n Philippin reported
ca e t e Bureau
2. Correctio spouse
the name was n of name
used. te p i of due to re-
of ar f Immigrati marriage -
2 Certificate
N t i on of Finality of
new Annulment/Nul
4. Required ID cards at m c Marriage lity or
and/or documents only ur e a foreign Contract/ annotated
for the following ali nt t governm Marriage Marriage
cases: za of i ent Certificat Contract/Certif
tio F o e and any icate, if due to
1. Correction of
n or n
issued ID
of the annulled or
name due to cards following, void marriage
is ei and/or with previously
naturalization whichever
su g C documen reported
from Filipino is
ed n e ts spouse
citizenship to applicable:
by A r
foreign th ff t
showing
1 Dea 3 Court Order
the new on Declaration
citizenship or e ai i th
name of
vice-versa - any P rs f Certific
(e.g., Presumptive
of the following: hil i ate of
Passport, Death, if
ip c spous
 previously eq w ported any of the Personal Record (SS
reported ui it spouse following, Forms E-1, RS-1,
spouse is va h whichever is OW-1, NW-1) duly
presumed
le p 5 Certificate
nt, r of Divorce applicable: received by the SSS
dead if e where the correct sex
du vi
(OCRG Form 1 Birth is indicated
4 Decree of e o No. 102), ifCorr Certificate
Divorce and to u due toecti
2 Passport 4 Court Order granting
Certificate of di sl divorce ofon petititon for correction
Naturalization vo y Muslim of 3 Member's of sex, if with
(granted rc r member withsex
before divorce) e e copy of erroneous entry of sex
or its previously - in Birth Certificate
 C. CERTIFICATION
SS NUMBER
I certify that the information provided in this form are true and correct.

PRINTED NAME SIGNATURE DATE

If member cannot sign, affix fingerprints (please see Instruction no. 5).
Below are the witnesses to fingerprinting:
1)
PRINTED NAME SIGNATURE DATE
ADDRESS & CONTACT NUMBER
2)
PRINTED NAME SIGNATURE DATE
RIGHT THUMB RIGHT INDEX
ADDRESS & CONTACT NUMBER
PART II - TO BE FILLED OUT BY SSS

For Change of Membership Type to For Change of Membership Type to

Self-Employed Non-Working Spouse
Business Code Working Spouse's MSC

Approved MSC Approved MSC of NWS

Start of Payment Start of Payment

Monthly SS Contribution (P) Monthly SS Contribution (P)

RECEIVED BY

SIGNATURE OVER PRINTED NAME DATE & TIME BRANCH

PROCESSED BY ENCODED BY

SIGNATURE OVER PRINTED NAME DATE & TIME SIGNATURE OVER PRINTED NAME DATE & TIME
REVIEWED BY APPROVED BY

SIGNATURE OVER PRINTED NAME DATE & TIME SIGNATURE OVER PRINTED NAME DATE & TIME

INSTRUCTIONS

1. Fill out this form in two (2) copies and submit to the nearest SSS branch office together with the required documents. Refer to the
attached "List of Documentary Requirements for Member Data Change Request".

2. Always indicate "N/A" or "Not Applicable", if the required data is not applicable.

3. Present original copy and submit photocopy/ies of the following identification (ID) card/s in filing this form:
1. Filed by member
1 Social Security (SS) card or Unified Multi-Purpose ID (UMID) card or two (2) ID cards both with signature and one (1) with
photo
2. Filed by employer or company representative or household employer
1. SS card or UMID card or two (2) ID cards of the member, both with signature and one (1) with photo; and
2. Additional ID card/s per type of filer
2.a Company ID of the employer-filer, with signature and photo, if filed by employer
2.b Specimen Signature Card (SS Form L-501) of the company representative, if filed by company representative
2.c Two (2) ID cards of the household employer-filer, both with signature and one (1) with photo, if filed by household employer

4. If member is requesting for updating of contact information (address, telephone number, e-mail address and mobile/cellphone
number), indicate already under Part I-A of the form the new contact information.

5. If member cannot sign, witnesses to fingerprinting shall be as follows:

1. Filed by member
1 SSS receiving personnel who shall affix his/her signature on the portion provided for in Part I-C.
2. Filed by employer or company representative or household employer
1 Two (2) witnesses. Both should affix their signatures and indicate their addresses and contact numbers on the portions
provided for in Part I-C. One (1) witness is the member's employer or company representative or household employer himself
and the other one (1) could be any person.

6. If dependents/beneficiaries are more than three (3), please use space provided below.
UPDATING OF DEPENDENT(S)/BENEFICIARY(IES) (Please check the appropriate box. )
NAME (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX) RELATIONSHIP TO MEMBER DATE OF BIRTH (MMDDYYYY)
New/Additional
1. Deletion
New/Additional
2. Deletion
New/Additional
3. Deletion
 New/Additional
4. Deletion
New/Additional
5. Deletion

Page 2 of 2
5. Change of civil status - any of the following, whichever is applicable
1. From single to married - Marriage Contract/Marriage Certificate
2. From married to legally separated - Decree of Legal Separation
3. From married to widowed
1. Death Certificate of spouse, if due to death of previously reported spouse
2. Court Order on the Declaration of Presumptive Death, if previously reported spouse is presumed dead
4. For reversion from married to single
1. If legally married to previously reported spouse
a.1 Certificate of Finality of Annulment/Nullity or annotated Marriage Contract/Marriage Certificate, if due to annulled or void marriage
with previously reported spouse
a.2 Decree of Divorce and Certificate of Naturalization (granted before divorce) or its equivalent, if due to divorce with previously
reported spouse
a.3 Certificate of Divorce (OCRG Form No. 102), if due to divorce of Muslim member with previously reported spouse
2. If not legally married to previously reported spouse
b.1 Certificate of No Marriage (CENOMAR) from Philippine Statistics Authority/National Statistics Office; and
b.2 Affidavit executed by the member attesting to the fact of the non-existence of marriage between him/her and the previously
reported spouse

6. Updating of contact information - No required documents

7. Updating of bank information - any one (1) of the following (must be single savings or current account only):
1 Passbook
2 For ATM, machine-validated deposit slip showing the name and bank account number of member
3 Any document showing the member's name and bank account number (e.g., print-out of online banking transaction, bank statement)

8. Updating of member record status (from "Temporary" to "Permanent")

1. Birth Certificate or in its absence, any of the following ID cards and/or documents:
1 Baptismal Certificate or its equivalent
2 Driver's License
3 Passport
4 Professional Regulation Commission (PRC) Card
5 Seaman's Book (Seafarer's Identification and Record Book)

2.In the absence of the above ID cards and/or documents, any two (2) of the following, both with the correct name and at least one (1) with
date of birth:
1 Alien Certificate of Registration 1 Home 9 Philippine Health
Development Mutual Insurance Corporation (PHIC)
2 ATM Card (with cardholder's name) Fund (Pag-IBIG) ID Card/ Member's Data
Transaction Record
3 Bank Account Passbook Card/Member's Data
Form 10 Police Clearance
4 Baptismal Certificate of child/ren or its equivalent
2 Homeowners 11 Postal ID Card
5 Birth Certificate of child/ren
Association ID Card 12 School ID Card
6 Certificate of Confirmation issued by National Commission on
3 ID Card issued by
Indigenous Peoples (formerly Office of Sourthern Cultural Community Local Government Units 13 Seafarer's Registration
and Office of Northern Cultural Community) Certificate issued by
(LGUs) (e.g., Philippine Overseas
Barangay/Municipality/City) Employment Administration
7 Certificate of Licensure/Qualification Documents from Maritime (POEA)
Industry Authority 4 ID Card issued by
professional association 14 Senior Citizen Card
8 Certificate of Muslim Filipino Tribal Affiliation issued by National recognized by PRC
Commission on Muslim Filipinos 15 Student Permit issued
9 Company ID Card
5 Life Insurance Policy by Land Transportation Office
6 Marriage (LTO)
10 Court Order granting petition for change of name or date of birth Contract/Marriage Certificate 16 Taxpayer's
11 Credit Card 7 National Bureau of Identification Number (TIN)
Card
12 Firearm License Card issued by Philippine National Police (PNP) Investigation (NBI)
Clearance 17 Transcript of Records
13 Fishworker's License issued by Bureau of Fisheries and Aquatic 8 Overseas Worker 18 Voter's Identification
Resources (BFAR)
Welfare Administration Card/Affidavit/Certificate of
14 Government Service Insurance System (GSIS) ID Card/ (OWWA) Card Registration
Member's Record/Certificate of Membership
1 Health or Medical Card 2. If Decree 1. If Spouse - any of the following,
child/re of whichever is applicable:
I. Updating of dependent(s)/beneficiary(ies) Adoptio
n - Birth 1 Decree of Legal Separation, if
1. For reporting of new/additional Certifica n
legally separated with previously
dependent(s)/beneficiary(ies) te or 2. For deletion reported spouse
Baptism
1. If spouse - Marriage al
of previously 2 Death Certificate of spouse, if
Contract/Marriage Certificate or SS reported due to death of previously
Certifica
Form E-4 of the spouse duly received dependent(s reported spouse
by the SSS where the name of the te or its
)/beneficiary
equival
member requesting the change is
reported as the spouse ent or
(ies) 3 Certificate of Finality of
Annulment/Nullity or annotated
 Marriage Contract/Certificate, if equi orte (OCRG Form No. 102), if due to
due to annulled or void marriage vale d divorce of Muslim member with
with previously reported spouse nt, if spo previously reported spouse
due use
4 Court Order on Declaration of to 2. If Parent/s - Death Certificate, if
Presumptive Death, if previously divo 6 C
reported spouse is presumed rce ertifi previously reported parent/s is/are
dead with cate already dead
pre
5 Decree of Divorce and viou of 3. If other beneficiary/ies - No required
sly Divo document/s
Certificate of Naturalization rce
(granted before divorce) or its rep