REPUBLIC OF THE PHILIPPINES

RECEIVED BY: SIGNATURE OVER PRINTED NAME DATE & TIME: BRANCH NAME:

SOCIAL SECURITY SYSTEM

(03-2013)

APPLICATION FOR VOLUNTARY PAYMENT OF CONTRIBUTIONS FOR MEMBERS AGED 65 YEARS OLD OR OVER (WITH LESS THAN 120 MONTHLY CONTRIBUTIONS)

THIS FORM IS NOT FOR SALE PLEASE READ INSTRUCTIONS AND TERMS AND CONDITIONS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK INK ONLY. PART I - MEMBER INFORMATION DATE OF BIRTH (MMDDYYYY) TIN (IF APPLICABLE) COMMON REFERENCE NO. (IF APPLICABLE) SS NUMBER NAME LOCAL ADDRESS
(BARANGAY/DISTRICT/LOCALITY)

(SURNAME)

(GIVEN NAME)

(MIDDLE NAME)

(SUFFIX)

(RM/FLR/UNIT NO. & BLDG. NAME)

(HOUSE/LOT/& BLK. NO.)

(STREET NAME)

(SUBDIVISION)

(CITY/MUNICIPALITY)

(PROVINCE)

ZIP CODE

TELEPHONE NO. (AREA CODE + TEL. NO.) FOREIGN ADDRESS (FOR OFW)

MOBILE/CELLPHONE NO.

E-MAIL ADDRESS

COUNTRY PART II - CERTIFICATION OF MEMBER

ZIP CODE

I hereby certify that the above information are true and correct, and that I agree on the condition that should I fail to pay continuously my voluntary contributions and should I pay less than the approved monthly salary credit (MSC), I will receive the lump sum retirement benefit. (MANDATORY)

SIGNATURE OVER PRINTED NAME OF MEMBER

DATE

(If member cannot sign, fingerprints should be witnessed by two persons) Witnesses to fingerprints:

RIGHT THUMB

RIGHT INDEX

1) SIGNATURE OVER PRINTED NAME DATE

2) SIGNATURE OVER PRINTED NAME DATE PART III - TO BE FILLED OUT BY THE SSS

TOTAL NUMBER OF CONTRIBUTIONS PAID: NUMBER OF LACKING CONTRIBUTIONS TO QUALIFY FOR RETIREMENT PENSION: DATE OF COMPLETION OF THE REQUIRED 120 MONTHLY CONTRIBUTIONS (mm/yyyy) DATE: ACTION TAKEN ON THE APPLICATION Approved Your approved Monthly Salary Credit (MSC) is P ___________, and the corresponding amount of your monthly contribution is P ___________. The start of your payment will be in ___________ and will end in ___________. Disapproved Reason : over 55 years old at the date of coverage (DOC) less than 80 monthly contributions late filing of application PROCESSED AND ENCODED BY: SIGNATURE OVER PRINTED NAME PERFORATE HERE SOCIAL SECURITY SYSTEM APPLICATION FOR VOLUNTARY PAYMENT OF CONTRIBUTIONS FOR MEMBERS AGED 65 YEARS OLD OR OVER (WITH LESS THAN 120 MONTHLY CONTRIBUTIONS)
(03-2013)

RECEIVED BY:

SIGNATURE OVER PRINTED NAME Branch

DATE & TIME

ACKNOWLEDGEMENT STUB NAME OF MEMBER

(Surname) (Given Name)

SS NUMBER

(Middle Name)

Note: Approved Monthly Salary Credit (MSC): P ________________

Amount of Monthly Contribution: P____________________

Start of Payment: _______________ End of Payment: ______________ Filing Date of Retirement Claim Application: _______________

INSTRUCTIONS 1) Accomplish Parts I and II of this form in one (1) copy without erasures or alterations. 2) Present Social Security (SS) card, or in its absence: any two valid IDs, both with signature and at least one with photo. If filed by members representative, the members representative must present his and the members SS card or two valid IDs, both with signature and at least one with photo and letter of authorization (LOA) signed by the member. 3) Sign over your printed name and affix your fingerprints (right thumb and right index) on the portions provided for in the application form. In case you could not sign, fingerprints should be witnessed by two persons. TERMS AND CONDITIONS A. ELIGIBILITY REQUIREMENTS 1. For members who are 65 years old or over prior to 01 April 2013 They must signify their intention to pay the lacking contributions by filing the Application for Voluntary Payment of Contributions for Members Aged 65 or Over (with less than 120 monthly contributions). Application form must be filed within 01 April 2013 to 01 July 2013. 2. For members who will turn 65 years old on or after 01 April 2013 They shall be allowed to pay the lacking contributions to complete the required contributions for retirement pension provided they meet the following conditions: a. Members should have been initially covered at age 55 or less; b. Members must have contributed at least 80 monthly contributions, including deemed paid contributions at age 65; c. The deadline for filing of the application shall be the end of the month following the 65th birthday of the member, e.g., 65th birth date is on 01 August 2013, deadline for filing of application is on 30 September 2013. 3. For members who are currently receiving pension for partial permanent disability benefit a. If 65 years old or over prior to 01 April 2013, they must signify their intention to pay the lacking contributions to qualify for retirement pension. They must file the Application for Voluntary Payment of Contributions for Members Aged 65 Years Old or Over within 01 April 2013 to 01 July 2013. The payment of the voluntary contributions shall start on the month after the last partial permanent disability pension (i.e., after the duration of the partial permanent disability benefit). b. Partial permanent disability pensioners who will turn 65 years old on or after 01 April 2013 shall be allowed to pay the lacking contributions to complete the required contributions for retirement pension subject to the conditions cited above. B. OTHER CONDITIONS 1. Members shall be allowed to continue paying contributions until they complete the required 120 monthly contributions for retirement pension. Payments in excess of 120 monthly contributions prior to the semester of contingency shall be refunded. 2. Members shall continuously pay without gap until the completion of the required 120 monthly contributions for retirement pension. Otherwise, the lump sum retirement benefit shall be paid. 3. Members shall pay based on the approved monthly salary credit (MSC). a. Decrease in the approved MSC shall be considered as stoppage of contribution payment. b. Payment in excess of the approved MSC shall be refunded to the member after the settlement of the retirement benefit. 4. Members who will not file the Application for Voluntary Payment of Contributions for Members Aged 65 years Old or Over (with less than 120 monthly contributions) shall no longer be allowed to continue paying and shall only be entitled to the lump sum retirement benefit. Those who will receive the lump sum benefit shall not be entitled to other benefits except for funeral benefit upon death. 5. The option to pay voluntarily ceases upon completion of the required number of contributions. Payments in excess of 120 monthly contributions prior to the semester of contingency shall be refunded. 6. No contributions shall be applied retroactively.