Republic of the Philippines

SOCIAL SECURITY SYSTEM SS NUMBER

E-1 PERSONAL RECORD 34-8219554-3
COV-01214 (09-2015) 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.
PLEASE READ THE INSTRUCTIONS AND REMINDERS 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 THE REGISTRANT

A. PERSONAL DATA
NAME (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX) DATE OF BIRTH (MMDDYYYY)
MACANAS MANOLITO GALUTAN JR. 0 1 2 0 1 9 9 2
SEX CIVIL STATUS TAX IDENTIFICATION NUMBER (IF ANY)

Male Female Single Married Widowed Legally Separated Others ________________ 7 3 7 4 6 0 5 1 5

NATIONALITY RELIGION PLACE OF BIRTH (CITY/MUNICIPALITY, PROVINCE) (CITY, COUNTRY, if born outside the Philippines)

FILIPINO IGLESIA NI CRISTO SAN FERNANDO CITY LA UNION

HOME ADDRESS (RM./FLR./UNIT NO. & BLDG. NAME) (HOUSE/LOT & BLK. NO.) (STREET NAME) (SUBDIVISION)
N/A 028 N/A
(BARANGAY/DISTRICT/LOCALITY) (CITY/MUNICIPALITY) (PROVINCE) (COUNTRY) ZIP CODE
MARIA CRISTINA WEST BANGAR LA UNION PHILIPPINES 2519
MOBILE/CELLPHONE NUMBER E-MAIL ADDRESS TELEPHONE NUMBER (COUNTRY CODE+ AREA CODE+ TEL. NO.)
09363586156 KATORZEX14@GMAIL.COM N/A
FATHER (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)

MACANAS MANOLITO BUTON SR.

MOTHER'S MAIDEN NAME (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)

MACANAS ROSARIO GALUTAN N/A

B. DEPENDENT(S)/BENEFICIARY/IES Check this box if using additional sheet.
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. MACANAS CRIS MATHEO DIEGO 0 7 2 1 2 0 1 3

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.
C. FOR SELF-EMPLOYED/OVERSEAS FILIPINO WORKER/NON-WORKING SPOUSE
SELF-EMPLOYED (SE) OVERSEAS FILIPINO WORKER (OFW) NON-WORKING SPOUSE (NWS)
Profession/Business Foreign Address SS No./Common Reference No. of Working Spouse
TECHNICIAN
Year Prof./Business Started Monthly Income of Working Spouse (P)
2012 Are you applying for membership I agree with my spouse's membership with SSS.
Monthly Earnings Monthly Earnings in the Flexi-Fund Program?
P P YES NO SIGNATURE OVER PRINTED NAME OF WORKING SPOUSE

D. CERTIFICATION
I certify that the information provided in this form are true and correct. Registrant is required to affix fingerprints.
(If registrant cannot sign, affix fingerprints in the presence of an SSS personnel.)

MANOLITO G. MACANAS JR. RIGHT THUMB RIGHT INDEX

PRINTED NAME SIGNATURE DATE
PART II - TO BE FILLED OUT BY SSS
BUSINESS CODE WORKING SPOUSE's MSC (FOR RECEIVED BY RECEIVED & PROCESSED BY
(FOR SE) NWS) (REPRESENTATIVE OFFICE/PARTNER AGENT) (MSS, BRANCH/SERVICEOFFICE/FOREIGN OFFICE)

P
MONTHLY SS CONTRIBUTION APPROVED MSC
(FOR SE/OFW/NWS) (FOR SE/OFW/NWS)
SIGNATURE OVER PRINTED NAME DATE & TIME SIGNATURE OVER PRINTED NAME DATE & TIME

P P REVIEWED BY
START OF PAYMENT FLEXI-FUND APPLICATION (MSS, BRANCH/SERVICE OFFICE)
(FOR SE/NWS) (FOR OFW)

Approved Disapproved SIGNATURE OVER PRINTED NAME DATE & TIME

 INSTRUCTIONS

1. Fill out this form and submit to the nearest SSS branch office together with the required documents.
2. Fill out the applicable portions as follows:
Parts I-A, B and D, if applying for SS number as pre-employment requirement
Parts I-A, B, C and D, if applying for Self-Employed, Overseas Filipino Worker (OFW) or Non-Working Spouse membership
- For Part I-B "DEPENDENT(S)/BENEFICIARY/IES", use "Additional Sheet for Dependent(s)/Beneficiary/(ies)", if necessary.
3. Always indicate "N/A" or "Not Applicable", if the required data is not applicable.
4. If this form is to be downloaded from the internet, please fill-out in two (2) copies.

REMINDERS

1. 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.
2. Your SS number is your lifetime number. You should not have more than one SS number.
3. 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:
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.

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).

A. ID Cards and/or Documents for the Issuance of SS Number ‒ Marriage Contract/Marriage Certificate
Birth Certificate, or in its absence, any of the following ‒ National Bureau of Investigation (NBI) Clearance
documents: ‒ Overseas Worker Welfare Administration (OWWA) card
‒ Baptismal Certificate or its equivalent ‒ Philippine Health Insurance Corporation (PHIC) ID
‒ Driver's License card/Member's Data Record
‒ Passport ‒ Police Clearance
‒ Professional Regulation Commission (PRC) card ‒ Postal ID card
‒ Seaman's Book (Seafarer's Identification and Record Book) ‒ School ID card
‒ Seafarer's Registration Certificate issued by Philippine
In the absence of the above ID cards and/or documents, any two Overseas Employment Administration (POEA)
(2) of the following documents both with the correct name and at ‒ Senior Citizen card
least one (1) with date of birth: ‒ 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
‒ Certificate of Confirmation issued by National Commission on ‒ Marriage Contract/Marriage Certificate or a copy of
Indigenous Peoples (formerly Office of Southern Cultural Member Data Change Request form (SS Form E-4)
Community and Office of Northern Cultural Community) of the spouse duly received by the SSS where the
‒ Certificate of Licensure/Qualification Documents from Maritime name of the registrant is reported as the spouse
Industry Authority For widowed
‒ Certificate of Muslim Filipino Tribal Affiliation issued by ‒ Marriage Contract/Marriage Certificate
National Commission on Muslim Filipinos ‒ Marriage Contract/Marriage Certificate and Death
‒ Company ID card Certificate of spouse or Court Order on the
‒ Court Order granting petition for change of name or date of Declaration of Presumptive Death, if previously
birth reported spouse is presumed dead
‒ Credit card For legally separated
‒ Firearm License card issued by Philippine National Police ‒ Decree of Legal Separation
(PNP) For annulled or with void marriage
‒ Fishworker's License issued by Bureau of Fisheries and ‒ Certificate of Finality of Annulment/Nullity or
Aquatic Resources (BFAR) annotated Marriage Contract/Marriage Certificate
‒ Government Service Insurance System (GSIS) card/ For divorced
Member's Record/Certificate of Membership ‒ Decree of Divorce and Certificate of Naturalization
‒ Health or Medical card (granted before divorce) or its equivalent
‒ Home Development Mutual Fund (Pag-IBIG) Transaction For divorced Muslim member
card/Member's Data Form ‒ Certificate of Divorce (OCRG Form No. 102)
‒ Homeowners Association ID card For reporting child/ren - whichever is applicable
‒ ID card issued by Local Government Units (LGUs) ‒ Birth Certificate/s or Baptismal Certificate/s or its
(e.g., Barangay/ Municipality/ City) equivalent
‒ ID card issued by professional association recognized by C. ‒ Decree of Adoption
PRC Documents for local enrolment in the Flexi-fund Program
‒ Life Insurance Policy Valid Overseas Employment Certificate (OEC) or E-
receipt issued by POEA
 Republic of the Philippines
SOCIAL SECURITY SYSTEM SS NUMBER
ADDITIONAL SHEET 34-8219554-3
COV-01214 (09-2015) 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.

PART I - TO BE FILLED OUT BY THE REGISTRANT

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

MACANAS MANOLITO GALUTAN JR.

ADDITIONAL DEPENDENT(S)/BENEFICIARY(IES)
CHILD/REN (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX) DATE OF BIRTH (MMDDYYYY)

1. MACANAS CRIS MATHEO DIEGO N/A 0 7 2 1 2 0 1 3

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.

MANOLITO G. MACANAS JR. March 01, 2019

PRINTED NAME OF REGISTRANT SIGNATURE DATE

PART II - TO BE FILLED OUT BY SSS

RECEIVED BY RECEIVED & PROCESSED BY REVIEWED BY
(REPRESENTATIVE OFFICE/PARTNER AGENT) (MSS, BRANCH/SERVICE OFFICE/FOREIGN OFFICE) (MSS, BRANCH/SERVICE OFFICE)

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME

DATE & TIME DATE & TIME DATE & TIME