SSS E-1 Form - Fill, Edit Online, Download & Print - No Signup
NAME
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
DATE OF BIRTH
(MMDDYYYY)
SEX
CIVIL STATUS
TAX IDENTIFICATION NUMBER
(IF ANY)
Male
Female
Single
Married
Widowed
Legally Separated
Others ________________
NATIONALITY
RELIGION
PLACE OF BIRTH
(CITY/MUNICIPALITY, PROVINCE) (CITY, COUNTRY
, if born outside the Philippines)
HOME ADDRESS
ZIP CODE
MOBILE/CELLPHONE NUMBER
E-MAIL ADDRESS
TELEPHONE NUMBER
(COUNTRY CODE+ AREA CODE+ TEL. NO.)
FATHER
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
MOTHER'S MAIDEN NAME
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
B. DEPENDENT(S)/BENEFICIARY/IES
SPOUSE
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
DATE OF BIRTH
(MMDDYYYY)
CHILD/REN
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
DATE OF BIRTH
(MMDDYYYY)
1.
2.
PLEASE
READ
THE
INSTRUCTIONS
AND
REMINDERS
AT
THE
BACK
BEFORE
FILLING
OUT
THIS
FORM.
ALL
INFORMATION
IN
CAPITAL
LETTERS
AND
USE BLACK INK ONLY
.
Republic of the Philippines
SOCIAL SECURITY SYSTEM
PERSONAL RECORD
FOR ISSUANCE OF SS NUMBER
THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE. THIS CAN ALSO BE DOWNLOADED THRU THE SSS WEBSITE AT www.sss.gov.ph.
PART I - TO BE FILLED OUT BY THE REGISTRANT
A. PERSONAL DATA
(RM./FLR./UNIT NO. & BLDG. NAME)
(HOUSE/LOT & BLK. NO.)
(STREET NAME)
(SUBDIVISION)
(BARANGAY/DISTRICT/LOCALITY)
(CITY/MUNICIPALITY)
(PROVINCE)
(COUNTRY)
Check this box if using additional sheet.
COV-01214
(09-2015)
SS NUMBER
E-1
3.
4.
5.
OTHER BENEFICIARY/IES
(If without spouse & child and parents are both deceased)
RELATIONSHIP
DATE OF BIRTH
(MMDDYYYY)
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
1.
2.
SELF-EMPLOYED (SE)
OVERSEAS FILIPINO WORKER (OFW)
NON-WORKING SPOUSE (NWS)
Profession/Business
Foreign Address
SS No./Common Reference No. of Working Spouse
Monthly Income of Working Spouse (P)
P
P
YES NO
P
P
P
C. FOR SELF-EMPLOYED/OVERSEAS FILIPINO WORKER/NON-WORKING SPOUSE
Year Prof./Business Started
Are you applying for membership
in the Flexi-Fund Program?
I agree with my spouse's membership with SSS.
Monthly Earnings
Monthly Earnings
RECEIVED & PROCESSED BY
(MSS, BRANCH/SERVICEOFFICE/FOREIGN OFFICE)
PART II - TO BE FILLED OUT BY SSS
SIGNATURE OVER PRINTED NAME OF WORKING SPOUSE
D. CERTIFICATION
I certify that the information provided in this form are true and correct.
(If registrant cannot sign, affix fingerprints in the presence of an SSS personnel.)
Registrant is required to affix fingerprints
.
PRINTED NAME
SIGNATURE
DATE
START OF PAYMENT
(FOR SE/NWS)
RECEIVED BY
(REPRESENTATIVE OFFICE/PARTNER AGENT)
FLEXI-FUND APPLICATION
(FOR OFW)
APPROVED MSC
(FOR SE/OFW/NWS)
WORKING SPOUSE's MSC
(FOR
NWS)
MONTHLY SS CONTRIBUTION
(FOR SE/OFW/NWS)
BUSINESS CODE
(FOR SE)
REVIEWED BY
(MSS, BRANCH/SERVICE OFFICE)
RIGHT THUMB
RIGHT INDEX
SIGNATURE OVER PRINTED NAME
SIGNATURE OVER PRINTED NAME
DATE & TIME
DATE & TIME
Approved Disapproved
(FOR SE/NWS)
(FOR OFW)
SIGNATURE OVER PRINTED NAME
DATE & TIME
1.
2. Fill out the applicable portions as follows:
Parts I-A, B, C and D, if applying for Self-Employed, Overseas Filipino Worker (OFW) or Non-Working Spouse membership
-
3.
4. If this form is to be downloaded from the internet, please fill-out in two (2) copies.
1.
2. Your SS number is your lifetime number. You should not have more than one SS number.
3.
3.1 Birth Certificate
3.2 Marriage Contract/Marriage Certificate
3.3 Death Certificate
4. All identification (ID) cards and/or documents with English translation issued by foreign government are acceptable.
A.
‒
Marriage Contract/Marriage Certificate
‒
National Bureau of Investigation (NBI) Clearance
‒
Overseas Worker Welfare Administration (OWWA) card
‒
Baptismal Certificate or its equivalent
‒
‒
Driver's License
‒
Passport
‒
Police Clearance
‒
Professional Regulation Commission (PRC) card
‒
Postal ID card
‒
Seaman's Book (Seafarer's Identification and Record Book)
‒
School ID card
‒
‒
Senior Citizen card
‒
Student Permit issued by Land Transportation Office (LTO)
‒
Alien Certificate of Registration
‒
Taxpayer's Identification Number (TIN) card
‒
ATM card (with cardholder's name)
‒
Transcript of Records
‒
Bank Account Passbook
‒
Voter's ID card/Affidavit/Certificate of Registration
‒
Baptismal Certificate of child/ren or its equivalent
B. Additional Supporting Documents
‒
Birth Certificate of child/ren
For married
‒
‒
‒
For widowed
‒
‒
Marriage Contract/Marriage Certificate
‒
‒
Company ID card
‒
‒
Credit card
For legally separated
‒
‒
‒
‒
‒
For divorced
‒
‒
Health or Medical card
‒
‒
‒
Homeowners Association ID card
For reporting child/ren - whichever is applicable
‒
‒
‒
C.
‒
Decree of Adoption
Documents for local enrolment in the Flexi-fund Program
‒
Life Insurance Policy
In the absence of the above ID cards and/or documents, any two
(2) of the following documents both with the correct name and at
least one (1) with date of birth:
Certificate
of Muslim
Filipino Tribal Affiliation
issued by
National Commission on Muslim Filipinos
Firearm License card issued by Philippine National Police
(PNP)
Fishworker's License issued by Bureau of Fisheries and
Aquatic Resources (BFAR)
Court Order granting petition for change of name or date of
birth
Seafarer's Registration Certificate issued by Philippine
Overseas Employment Administration (POEA)
Certificate of Confirmation issued by National Commission on
Indigenous Peoples (formerly Office of Southern Cultural
Community and Office of Northern Cultural Community)
Certificate of Licensure/Qualification Documents from Maritime
Industry Authority
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:
LIST OF DOCUMENTARY REQUIREMENTS
New registrant who is over sixty (60) years old and not a surviving spouse pensioner/guardian of a pensioner, is not qualified to apply for
an SS number.
Birth
Certificate
,
or
in
its
absence,
any of
the
following
documents:
Philippine
Health
Insurance
Corporation
(PHIC)
ID
card/Member's Data Record
INSTRUCTIONS
Fill out this form and submit to the nearest SSS branch office together with the required documents.
Parts I-A, B and D, if applying for SS number as pre-employment requirement
REMINDERS
For Part I-B "DEPENDENT(S)/BENEFICIARY/IES", use "Additional Sheet for Dependent(s)/Beneficiary/(ies)", if necessary.
Always indicate "
N/A
" or
"Not Applicable
", if the required data is not applicable.
Always present the original or certified true copy/ies when submitting the photocopy/ies of the required ID card(s) and/or document(s).
ID Cards and/or Documents for the Issuance of SS Number
Decree of Legal Separation
Certificate of Divorce (OCRG Form No. 102)
Marriage Contract/Marriage Certificate
or
a copy of
Member Data Change Request form (SS Form E-4)
of the spouse duly received by the SSS where the
name of the registrant is reported as the spouse
Marriage Contract/Marriage Certificate
and
Death
Certificate
of
spouse
or
Court
Order
on
the
Declaration
of
Presumptive
Death,
if
previously
reported spouse is presumed dead
Valid Overseas Employment Certificate (OEC) or E-
receipt issued by POEA
Decree of Divorce
and
Certificate of Naturalization
(granted before divorce) or its equivalent
For annulled or with void marriage
Certificate
of
Finality
of
Annulment/Nullity
or
annotated Marriage Contract/Marriage Certificate
ID
card
issued
by
Local
Government
Units
(LGUs)
(e.g., Barangay/ Municipality/ City)
ID card issued by professional association recognized by
PRC
Birth Certificate/s
or
Baptismal Certificate/s or its
equivalent
For divorced Muslim member
Government
Service
Insurance
System
(GSIS)
card/
Member's Record/Certificate of Membership
Home Development Mutual Fund (Pag-IBIG) Transaction
card/Member's Data Form
NAME
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
CHILD/REN
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
DATE OF BIRTH
(MMDDYYYY)
1.
2.
3.
4.
5.
OTHER BENEFICIARY/IES
(If without spouse & child and parents are both deceased)
RELATIONSHIP
DATE OF BIRTH
(MMDDYYYY)
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
1.
2.
RECEIVED BY
RECEIVED & PROCESSED BY
REVIEWED BY
(REPRESENTATIVE OFFICE/PARTNER AGENT)
(MSS, BRANCH/SERVICE OFFICE/FOREIGN OFFICE)
(MSS, BRANCH/SERVICE OFFICE)
PART II - TO BE FILLED OUT BY SSS
DATE
SIGNATURE OVER PRINTED NAME
SIGNATURE OVER PRINTED NAME
SIGNATURE OVER PRINTED NAME
PRINTED NAME OF REGISTRANT
SIGNATURE
PART I - TO BE FILLED OUT BY THE REGISTRANT
Republic of the Philippines
SOCIAL SECURITY SYSTEM
ADDITIONAL SHEET
FOR DEPENDENT(S)/BENEFICIARY(IES)
THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE. THIS CAN ALSO BE DOWNLOADED THRU THE SSS WEBSITE AT www.sss.gov.ph.
FILL OUT THIS FORM IN TWO (2) COPIES. PRINT ALL INFORMATION IN CAPITAL LETTERS AND
USE BLACK INK ONLY
.
ADDITIONAL DEPENDENT(S)/BENEFICIARY(IES)
COV-01214
(09-2015)
SS NUMBER
SIGNATURE OVER PRINTED NAME
DATE & TIME
SIGNATURE OVER PRINTED NAME
DATE & TIME
SIGNATURE OVER PRINTED NAME
DATE & TIME
