Republic of the Philippines SOCIAL SECURITY SYSTEMANNUAL CONFIRMATION OF PENSIONER'S FORM ''Pensioner's Reply(Use black ink only in accomplishing

this form) (01-2012) SS NUMBER OF MEMBERSS NUMBER OF PENSIONER MAILING ADDRESS OF PENSIONER (No. & Street) (Barangay) (Town District) (City/Province ) (Postal Code) OF PENSIONERDATE OF BIRTHE- MAIL ADDRESSMOBILE NO.LANDLINE/NAME OF MEMBER (Surname) (Given Name) (Middle Name) PART I - MEMBER'S / PENSIONER'S DATANAME OF PENSIONER (Surname) (Given Name) (Middle Name) TYPE OF PENSION/S: RetirementSS Total DisabilityEC Total DisabilitySS DeathEC Death1. For total dis ability/retirement pensioner, have you been re-employed/resumed self-employment ?YesNoIf yes, name and address of present employer :Datere-emloedorresumedself-e mloment: PART II - QUESTIONNAIRE(mm/dd/yyyy) 2. For death pensioner, have you re-married or currently cohabiting with anothe r person ?YesNoIf yes, name of spouse/partner:Date of marriage/cohabitation:3. A re you under the care and custody of a guardian?YesNoIf yes, name and address of guardian:4. Is there any dependent child who already got married, employed or d ied ?YesNoIf yes, fill out the data below: DATE OFNAME OF DEPENDENT CHILDRENEMPLOYMENT 3 NAME OF GUARDIAN,IF APPLICABLEDATE OF MARRIAGE SS NO. 1 DATE OF DEATH 245 I hereby certify that the foregoing information is complete, true and correct to the best of my knowledge. OF PENSIONER(If unable to sign, affix fingerprints with the signature of two wit nessesSIGNATURE OVER PRINTED NAME DATE RIGHT THUMB RIGHT INDEX 1)2)SIGNATURE OVER PRINTED NAME PART III - CERTIFICATION OF BANK MANAGER/BARANGAY CHAIRMAN DATE,and submit photocopy of one valid ID with photo and signature of eachwitnes s) (For Retiree and Death Pensioners) SIGNATURE OVER PRINTED NAME DATEBelow are the witnesses to fingerprinting:Check the appropriate box (one only):Bank ManagerBarangay ChairmanThisistocertifythatM r./Ms._____________________________________________,adepositor/bonafideresidento f __________________________________________________________________personallyap pearedbeforetheundersignedon ___________________________ as compliance to the an nual confirmation of pensioners being conducted by the Social Security System. SIGNATURE OVER PRINTED NAME( D E T A C H B E L O W T H I S L I N E ) SS NUMBER OF MEMBER/PENSIONERNOTICE:Anyonewhofalsifiesessentialinformationreques tedbythisorarelatedformmay,uponconviction,besubjecttofineandimprisonment under t he law (Sec. 28 (a) of the Social Security Law and Art.207 (b) Chapter IX of PD # 626). DATE (Surname) (Given Name) (Middle Name)

NOTICE OF SCHEDULEISSUED BY: SIGNATURE OVER PRINTED NAMEOF SSS / BANK PERSONNELDATEDESIGNATIONPlease report f or your Annual Confirmation anytime within the month of _________________; other wise your pension will be suspended.

For SSS Use Only Type of Compliance :PersonalThru BankThru RepresentativeThru Mail PART IV - DOCUMENTS SUBMITTED AbroadIncapacitatedBarangay OfficialInstitutionSigned letterSigned letterAccomli shedACOPFormAccomlishedACOPForm PENSIONER IS LIVING ABROADPENSIONER IS A LOCAL RESIDENT Photocopy of valid passportSketch of residencePhotocopy of SS CardCertification fromPhotocopy of valid ID issued by host country governmental unit/Barangayagen cy (Pls. specify) InstitutionPhotocopy of two (2) valid IDs (Pls. Specify)Bank1) Medical Certificate2DeathCertificate Medical CertificateComplete physical exami nation reportDeath Certificate Relevant laboratory or diagnostic resultComplete physical examination reportSS CardRelevant laboratory or other diagnostic exam r esultsTwo (2) valid IDs (Pls. specify)1)_______________________ Certification is sued by (Pls. specify) 2)_______________________ ACTION TAKEN/REMARKS Identity of pensioner establishedFor data captureFor interview (Lacks valid IDs for the issuance of SS No./Data Capture, etc.)Deceased PensionerOthers _________ _______________________________________ INTERVIEWED & SCREENED BY (Date of Death)ContinueSuspend (Reason)_________________________________________ __________________________________________________ Cancel (Reason) _____________ _______________________________________________________________________________ PART V - RECOMMENDATION SIGNATURE OVER PRINTED NAMEDATEDESIGNATIONRe-adjudicate (Reason) _______________ ________________________________________________________________________ Returne d (Reason) _____________________________________________________________________ _____________________ Pending (For further evaluation)X-ray/ECG for readingFor M edical Fieldwork Services (MFS)For Fact of Pensioner's Existence (FPE)For referr al to other branch/unitOthers REVIEWED & RECOMMENDED BYAPPROVED BY SIGNATURE OVER PRINTED NAMEDESIGNATIONDATESIGNATURE OVER PRINTED NAMEDESIGNATION DATE