Republic of the Philippines

SOCIAL SECURITY SYSTEM

R T 0 2 220 5
FUNERAL CLAIM APPLICATION

mls rank ucy ae neeaoouceD also is uot roe arse. zuia can cLeo aa oowui.oboes zHnu one aas wsealn AT www.••a.ge•.ph
PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS ANO U4E BLACK INK ONLY.
rAAT I - •o ae rccED OUT B• CMiu•NT
A. DECEASED MEMBER'S INFORMATION
SS NUMBER COMMON REFERENCE NUMBER iiF Nyi DATE OF BIRTH ‹uuooYYw› SEX

NAME (WT NME) IGIRSt nWE) {MIDDLE NAME) {SUFFIX)

ADDRESS CRM SLA UNIT NO 4 8LDG IAME) IHOUSE/LOT 4 BLK NO ) (STREET NAME) tSu8Dlvi6iON)

{COUNTRYS ZIP CODE

CIVIL STATUS
Single Married Widowed Legally Separated Olhers (Pls. indicale)
DATE OF DEATH {MMDD ) PLACE OF DEATH DATE OF INTERMENTiuuoo PLACE OF INTERMENT

B. CLAIMANT'S INFORMATION
NAME RELATIONSHIP TO MEMBER

SS NUMBER lir Any COMMON REFERENCE NUMBER ‹ir Army DATE OF BIRTH {MMDDWW1 SEX

I I I I I I I I I I I I I I I I I I I I I I I I Male Female

BARANGAYOIGTRICT/LOCALITY) (COUNTRY) ZIP CODE

TELEPHONE NUMBER t • . MOBILE/CELLPHONE NUMBER E-MAIL ADDRESS

C. CERTIFICATION
T eeAlfy that the Infonnatlon provldad In thle form are true and corz•ct and that I have no prior or pending claim for
Funeral Benefit

OFF P N ED N C IM N SIGNATURE OF CLAIMANT DATE

If claimant cannot eqn, affix fingerprints (phase see Instruction no. 5) RECENT
Below are the wTtnoss to fingcrprlntlng: 1X1 ID

PRINTED NAME SGNATURE DATE

MABA RE S CO TACTN

PRINTED NAME SIGNATURE DATE

RIGHT THUMB RIGHT INDEX

ADDRESS & CONTACT NUMBER

If addTtlonsT Information about me or the deceased member ie r•quTrcd. tfie SSS may reach the qezsona below:
N8me Address Gonlacl Number

Nepuglic ot tne P'nilippines

SOCIAL SECURITY 9Y9TEM
FUNERAL CLAIM APPLICATION
ACKNOWLEDGEMENT STUB
SS NO./COMMON REFERENCE NO. «r a^n'› )NAME OF DECEASEO MEMBER M’

i
RECEIVED BY REMARKS

SIGNATURE OVER PRINTED NAME POSITION TITLE DATE 4 TIME BRANCH

 PART’ II • TO BE FILLED OUTBY 9SS
TYPE OF CLAIM

SS EC WARNING
TAX IDENTIFICATION NUMBER OF THE CLAIMANT @ 'n
ANY PERSON
IS DECEASED WHO
MEMBER MAKESRECEIVING
CURRENTLY ANY FALSE STATEMENT IN THIS APPLICATION OR SUBMITS ANY FALSIFIED DOCUMENT IN CONNEC
PENSIONS
{SECTION 28 OF R.A. 8282).
Yes (Pls. chect type of pensionYs) No No knowledge
TYPE OF PENSION/S
Retirement

Death
IF RECEIVING SURVIVOR'S PENSION, INOICATE SS NO./COMMON REFERENCE NO. iir AN AN0 NAME OF MEMBER
sS No./Common Reference No. Name of Dacaased Member \+^' ^^M^)

IF RECEIVING PENSION AS GUARDIAN OF RETIREE/DISABILITY/SURVIVOR PENSIONER, INDICATE SS NO./COMMON REFERENCE NO. tir AN'0 AND NAME
OF MEMBER
SS No./Common fteference No. Name of Member
FINDINGS
No Pending Claim
Deceased pensioner has over paid benefit in the amount of P
Benefit”)
Employment History Validated
Others tsnecxy):
RECEIVED & PROCESSED BY

STGMATUR£ OVER PRINTED MME DATE

REVIEWED BY

SIGNATURE OVER PRINTED BE

APPROVED BY

SIGMTtjRE OVER PRINCED NAME

INSTRUCTIONS

1. Fill out this form in one (1) copy.

2. Always indicate "M/A" or "Not Applicable". if Ihe required data is not applicable.
3. Affix your initials on all alterations/erasures in this form.
4. Affix your signature and attach your recent (1 x 1) ID picture on the portions provided for in Part I-C.
s. If claimantcannot sign, witnesses to fingergrinting shall be as follows:
a. Filed by claimant
• SSS receiving personnel who shall affix his/her signature on the space provided and indicate employee number and branch on
the "Address and Contact Number" potions provided in Part I-C
b. Filed by authorized representative
• Two (2) witnesses. One (1) is Ihe claimant's representative and the other one (1) could be any person. Both should affix
their signatures and indicate their addresses and contact numbers on the portions provided in Pan 1-C
6. Please refer to the attached "Llst of Documentary Requirements for Funeral Benefit Proceaa" for the documentary requirements and
identification cards/documents.

REMINDER

Verification of status of claim may be made thru lhe SSS Website at www.sss gov.ph or contact our Call Center at 920-6446 -
55 or 917-7777