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    SSSForm Death Claim Part1 Part1 Front

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    Denn Galura
    This document is a death claim application form from the Social Security System of the Philippines. It contains information about the deceased member - Isagani Galura, including his social security number, date of birth, date and place of death. It also lists his employment history and whether he has any dependent children. The form provides details about the claimant, Nenita Galura, who is the deceased's spouse. It indicates Nenita's preferred mode of payment is cash card upon approval of the death claim.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    SSSForm Death Claim Part1 Part1 Front

    Uploaded by

    Denn Galura
    40 views1 page
    This document is a death claim application form from the Social Security System of the Philippines. It contains information about the deceased member - Isagani Galura, including his social security number, date of birth, date and place of death. It also lists his employment history and whether he has any dependent children. The form provides details about the claimant, Nenita Galura, who is the deceased's spouse. It indicates Nenita's preferred mode of payment is cash card upon approval of the death claim.

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    application form part 2

    Original Title

    SSSForm_Death_Claim_Part1_Part1_Front

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    This document is a death claim application form from the Social Security System of the Philippines. It contains information about the deceased member - Isagani Galura, including his social security number, date of birth, date and place of death. It also lists his employment history and whether he has any dependent children. The form provides details about the claimant, Nenita Galura, who is the deceased's spouse. It indicates Nenita's preferred mode of payment is cash card upon approval of the death claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    40 views1 page

    SSSForm Death Claim Part1 Part1 Front

    Uploaded by

    Denn Galura
    This document is a death claim application form from the Social Security System of the Philippines. It contains information about the deceased member - Isagani Galura, including his social security number, date of birth, date and place of death. It also lists his employment history and whether he has any dependent children. The form provides details about the claimant, Nenita Galura, who is the deceased's spouse. It indicates Nenita's preferred mode of payment is cash card upon approval of the death claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Republic of the Philippines

    SOCIAL SECURITY SYSTEM


    DEATH CLAIM APPLICATION
    (04-2012)
    PART I Please read the instructions at the back of the form before filling-up the application. Print information in capital letters and use black ink only.
    MEMBER'S INFORMATION
    SS NUMBER NAME OF MEMBER (Surname) (Given Name) (Middle Name)

    0 3 3 5 1 5 1 4 2 0 GALURA ISAGANI NICOLAS


    DATE OF BIRTH (mm-dd-yyyy) DATE OF DEATH (mm-dd-yyyy) PLACE OF DEATH (Town/District) (City/Province)
    1 1 1 0 1 9 5 4 0 9 2 8 2 0 2 2 PROJ. 4, QUEZON CITY. NCR
    TYPE OF CLAIM CIVIL STATUS
    Social Security Employees’ Compensation Single Married Legally Separated Widow/Widower
    EMPLOYMENT HISTORY (Use separate sheet, if necessary)
    PERIOD OF EMPLOYMENT (mm-yyyy)
    NAME OF EMPLOYER ADDRESS
    From To
    1. SQUIRES BINGHAM MFG. CO. INC
    ARMSCOR AVE. PARANG MARIKINA CITY 0 3 1 9 7 5 0 2 1 9 8 0
    2. ARMSCOR GLOBAL DEFENCE INC. ARMSCOR AVE. PARANG MARIKINA CITY 0 3 1 9 8 0 0 9 2 0 1 4

    3.
    4.

    DEPENDENT CHILDREN (Below 21 years old or above 21 but incapacitated)


    CHECK APPLICABLE
    DATE OF BIRTH COLUMN
    NAME OF CHILDREN Legitimate Illegitimate
    ADDRESS
    (mm-dd-yyyy)

    1. n/a n/a n/a n/a


    2.
    3.
    4.
    5.
    CLAIMANT'S INFORMATION
    SS NUMBER (If any) NAME OF CLAIMANT (Surname) (Given Name) (Middle Name)

    GALURA NENITA SISON


    ADDRESS (Number, Street and Subdivision) (Barangay) (Town/District) (City/Province) POSTAL CODE
    20 BANTAYOG ST. CONCEPCION UNO, MARIKINA CITY. NCR 1 8 0 7
    DATE OF BIRTH (mm-dd-yyyy) GENDER RELATIONSHIP TO MEMBER
    0 2 1 9 1 9 6 2 Male Female SPOUSE
    TIN TELEPHONE (Including Area Code) / MOBILE NO. PREFERRED MODE OF PAYMENT
    n/a 0 9 1 9 7 4 0 7 3 4 4 Cash Card ATM/Passbook
    PERFORATE HERE
    RECEIVED BY:
    SOCIAL SECURITY SYSTEM
    DEATH CLAIM APPLICATION
    ACKNOWLEDGMENT STUB
    (04-2012) SIGNATURE OVER PRINTED NAME DATE
    PLEASE PRESENT THIS WHEN INQUIRING ABOUT THE STATUS OF YOUR APPLICATION. VERIFICATION
    WILL BE ENTERTAINED AFTER _____ DAYS FROM THE DATE OF RECEIPT. YOU MAY VERIFY THRU
    SSS WEBSITE AT www.sss.gov.ph.
    RECEIVING BRANCH
    SS NUMBER NAME OF MEMBER (Surname) (Given Name) (M.I.)

    0 3 3 5 1 5 1 4 2 0 GALURA ISAGANI N.

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