Republic of the

Philippines

SOCIAL SECURITY SYSTEM

E-4

MEMBER DATA CHANGE REQUEST

COV-01215 (09-2015)
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 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 MEMBER

A. PERSONAL DATA
SS NUMBER
NAME

COMMON REFERENCE NUMBER (IF ANY)

(LAST NAME)

ADDRESS

DATE OF BIRTH (MMDDYYYY)

(FIRST NAME)

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

(SUBDIVISION)

(BARANGAY/DISTRICT/LOCALITY)

TELEPHONE NUMBER (AREA CODE + TEL. NO.) MOBILE/CELLPHONE NUMBER

(MIDDLE NAME)

(CITY/MUNICIPALITY)

Employed
Voluntary
Overseas Filipino Worker
Non-Working Spouse (NWS)
Prior Registrant
(A person who registered with the SSS for the first time as a prospective employee. )

CORRECTION OF NAME

(PROVINCE)

ZIP CODE

E-MAIL ADDRESS

B. DATA CHANGE/CORRECTION/UPDATING

B.

(STREET NAME)

COUNTRY

CHANGE OF MEMBERSHIP TYPE

FROM

(SUFFIX)

(HOUSE/LOT & BLK NO.)

FOREIGN ADDRESS (IF APPLICABLE)

A.

TAX IDENTIFICATION NUMBER (IF ANY)

ZIP CODE

TO

TO (Option for Prior Registrant Only)

Self-Employed (Please fill-out the details below.)

Non-Working Spouse (Please fill-out the details below.)

Profession/Business

SS No./CRN of Working Spouse

Year Profession/Business Started

Monthly Income of Working Spouse (P)

Monthly Earnings (P)

I AGREE WITH MY SPOUSE'S MEMBERSHIP WITH SSS.

SIGNATURE OVER PRINTED NAME OF WORKING SPOUSE

FROM

TO

Last Name

First Name

Middle Name
(or change of middle initial to middle name)

Prefix (e.g., "de", "dela", "delos",

"del", "Ma." or "Maria") or Suffix
(e.g., Jr., II or III)
Simple Error in Spelling of Name
(e.g., "i" to "e" or "u" to "o" or vice
versa; inclusion/ deletion of space
and special characters)

3.
4.

5.

Due to to Re-marriage
CORRECTION OF DATE OF BIRTH
CORRECTION OF SEX

CHANGE OF CIVIL STATUS

(For Female members: Accomplish the
FROM and TO portions, if also
requesting for change of name)
Single to Married
Married to Legally Separated

U
P
D
A
T
I
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B
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r
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P
e

G.
UPDATING OF BANK
INFORMATION
Bank Name

F.
UPDATI
NG OF
CONTAC
T
INFORM
ATION
Address

Married to Widowed

8.

Re
ver
sio
n
fro
m
Ma
rrie
d
to
Sin
gle

DENT(S)/BENEFICI
ARY(IES)
(Please
check
the
appropriate box. If
more than 3, use
other
page
"Instructions"
portion.)

r
m
a
n
e
n
t
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)
p
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s

9.

U
P
D
AT
IN
G
O
F
D
EP
E
N

Benefits (Sickness/
Maternity/Partial
Disability)
Loans
PESO Fund

E-mail
Address

Bank Branch
M
ob
ile
/C
ell
ph
on
e
N
u
m
be
r

Accou
Numbe

NAME

(LAST NAME)

(FIRST NAME)

(MIDDLE NAME)

(SUFFIX)

RELATIONSHIP TO MEMBER

DATE OF BIRTH (MMDDYYYY)

1.

New/Additional
Deletion

2.

New/Additional
Deletion

3.

New/Additional
Deletion

Pag

e 1 of 2

REMINDERS

1. 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:

1.1Birth Certificate
1.2Marriage Contract/Marriage Certificate
1.3Death Certificate
2. All ID cards and/or documents with English translation issued by foreign governments 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).

1.

Change of membership type

1. To Self-Employed - No required documents

2. To Non-Working Spouse - Marriage Contract/Marriage Certificate or a copy of Working Spouse's Member Data Change Request form (SS
Form E-4) duly received by the SSS where the name of the NWS is indicated as the spouse

B./C. Correction of name and/or Correction of date of birth

1. Birth Certificate or Passport.

2. In the absence of the Birth Certificate and Passport, the following are the required ID cards and/or documents:
1. Certificate of Non-Availability of Birth Records from the City or Municipal Civil Registrar or Philippine Statistics Authority/National
Statistics Office or National Archives, for the alleged correct name/date of birth; and

2.
ID Cards

1
2
3
4
5

Any TWO (2) of the following, both with the correct name and at least one (1) with date of birth:
Documents

Alien Certificate
Registration

Driver's License
Firearm License Card issued by Philippine National Police
Government Service Insurance System (GSIS) ID Card
Health or Medical Card
Home Development Mutual Fund (Pag-IBIG) Transaction Card

ID Card issued by Local Government Units (LGUs) (e.g.,

Barangay/Municipality/City)

7
8
9
10
11
12
13

Overseas Worker Welfare Administration (OWWA) Card

Philippine Health Insurance Corporation (PHIC) ID Card
Postal ID Card
Professional Regulation Commission (PRC) Card
Senior Citizen Card
Taxpayer's Identification Number (TIN) Card
Voter's Identification Card

3. Required

additional ID cards and/or documents

personal

2.

If for correction to who have

(2) names refer to
one (1) and the
same person and
the reason why
the name was
used.

4.

Required ID cards
and/or documents only
for
the
following
cases:

1.

Correction
of
name
due
to
naturalization
from
Filipino
citizenship
to
foreign
citizenship
or
vice-versa - any
of the following:

C
ert
ifi
ca
te
of
N
at
ur
ali
za
tio
n
is
su
ed
by
th
e
P
hil
ip

Record/Certificate
Membership
of

Baptismal Certificate or
its equivalent (member's)

Birth
Certificate/Baptismal
Certificate or its equivalent
(child/ren's)

Certificate
of
Licensure/Qualification
Documents from Maritime
Industry Authority

Certificate of Muslim
Filipino Tribal Affiliation
issued
by
National
Commission on Muslim
Filipinos

Court Order granting

petition for change of name
or date of birth

8
9

of

Life Insurance Policy

Marriage
Contract/Marriage Certificate

10

National
Bureau
of
Investigation (NBI) Clearance

11

Pag-IBIG Member's Data

Form

12

PHIC
Record

13
14

Member's

Data

Police Clearance

Seaman's
Book
(Seafarer's Identification and
Record book)

15

Student Permit issued by

Land Transportation Office
(LTO)

16
17

Transcript of Records

Voter's
Affidavit/Certificate
of
7
GSIS
Member's
Registration
for the following
and submitted birth certificate is registered
1. If
for
after the 55th birthday - two (2) ID cards
cases:
correction of
and/or documents in Item 2.b above.
date of birth
totally
name (except if due to
and ces on the use of the different
different
naturalization) - Joint Affidavit of two circu name/middle name stating
name/middle (2) persons knowledge of the facts
mstan therein that the two
pi
I
ate
Driver's
e, if due to
n
d
issued by
License)
death
of
e
e
the
previously
D
n
Philippin
reported
2. Correctio
e
t
e Bureau
spouse
n of name
p
i
of
due to re2 Certificate
ar
f
Immigrati
marriage of Finality of
t
i
on
new
Annulment/Nul
m
c
Marriage

lity
or
e
a
Contract/
annotated
foreign
Marriage
nt
t
Marriage
governm
Contract/Certif
Certificat
of
i
ent
icate, if due to
e and any
F
o
issued ID
annulled
or
of
the
or
n
cards
void marriage
following,
ei
and/or
with previously
whichever
g
C
reported
documen
is
spouse
n
e
ts
applicable:
A
r
showing
3 Court Order
1 Dea
ff
t
the new
on Declaration
th
ai
i
name
of
Certific
rs
f
(e.g.,
Presumptive
ate
of
i

Passport,
Death,
if
spous
c

previously
reported
spouse
presumed
dead

is

Decree
of
Divorce
and
Certificate of
Naturalization
(granted
before divorce)
or
its

eq
ui
va
le
nt,
if
du
e
to
di
vo
rc
e

w
it
h
p
r
e
vi
o
u
sl
y
r
e

ported
spouse

Certificate
of
Divorce
(OCRG Form
No. 102), ifCorr
due
toecti
divorce
ofon
Muslim
of
member withsex
previously
-

any
of
following,
whichever
applicable:

the
is

1 Birth
Certificate

4 Court

2 Passport
3 Member's
copy

Personal Record (SS

Forms E-1, RS-1,
OW-1, NW-1) duly
received by the SSS
where the correct sex
is indicated

of

Order granting
petititon for correction
of
sex,
if
with
erroneous entry of sex
in Birth Certificate

C. CERTIFICATION
SS NUMBER

I certify that the information provided in this form are true and correct.

PRINTED NAME

SIGNATURE

DATE

If member cannot sign, affix fingerprints (please see Instruction no. 5).
Below are the witnesses to fingerprinting:
1)
PRINTED NAME

SIGNATURE

DATE

SIGNATURE

DATE

ADDRESS & CONTACT NUMBER

2)
PRINTED NAME
ADDRESS & CONTACT NUMBER

RIGHT THUMB

RIGHT INDEX

PART II - TO BE FILLED OUT BY SSS

For Change of Membership Type to

For Change of Membership Type to

Self-Employed

Non-Working Spouse

Business Code

Working Spouse's MSC

Approved MSC

Approved MSC of NWS

Start of Payment

Start of Payment

Monthly SS Contribution (P)

Monthly SS Contribution (P)

RECEIVED BY

SIGNATURE OVER PRINTED NAME

PROCESSED BY

DATE & TIME

ENCODED BY

BRANCH

SIGNATURE OVER PRINTED NAME

REVIEWED BY

DATE & TIME

SIGNATURE OVER PRINTED NAME

APPROVED BY

DATE & TIME

SIGNATURE OVER PRINTED NAME

DATE & TIME

SIGNATURE OVER PRINTED NAME

DATE & TIME

INSTRUCTIONS

1.

Fill out this form in two (2) copies and submit to the nearest SSS branch office together with the required documents. Refer to the
attached "List of Documentary Requirements for Member Data Change Request".

2.

Always indicate "N/A" or "Not Applicable", if the required data is not applicable.

3.

Present original copy and submit photocopy/ies of the following identification (ID) card/s in filing this form:

1.

Filed by member

Social Security (SS) card or Unified Multi-Purpose ID (UMID) card or two (2) ID cards both with signature and one (1) with

photo

2.

Filed by employer or company representative or household employer

1.
2.

SS card or UMID card or two (2) ID cards of the member, both with signature and one (1) with photo; and
Additional ID card/s per type of filer
2.a Company ID of the employer-filer, with signature and photo, if filed by employer
2.b Specimen Signature Card (SS Form L-501) of the company representative, if filed by company representative
2.c Two (2) ID cards of the household employer-filer, both with signature and one (1) with photo, if filed by household employer

4.

If member is requesting for updating of contact information (address, telephone number, e-mail address and mobile/cellphone
number), indicate already under Part I-A of the form the new contact information.

5.

If member cannot sign, witnesses to fingerprinting shall be as follows:

1.

Filed by member

1
2.

SSS receiving personnel who shall affix his/her signature on the portion provided for in Part I-C.

Filed by employer or company representative or household employer

Two (2) witnesses. Both should affix their signatures and indicate their addresses and contact numbers on the portions
provided for in Part I-C. One (1) witness is the member's employer or company representative or household employer himself
and the other one (1) could be any person.

6.

If dependents/beneficiaries are more than three (3), please use space provided below.
UPDATING OF DEPENDENT(S)/BENEFICIARY(IES) (Please check the appropriate box. )
NAME
1.
2.
3.

(LAST NAME)

(FIRST NAME)

(MIDDLE NAME)

(SUFFIX)

RELATIONSHIP TO MEMBER

DATE OF BIRTH (MMDDYYYY)

New/Additional
Deletion

New/Additional

Deletion

New/Additional

Deletion

4.

New/Additional

Deletion

New/Additional

5.

Page 2 of 2

Deletion

5.

Change of civil status - any of the following, whichever is applicable

1.
2.
3.

From single to married - Marriage Contract/Marriage Certificate

From married to legally separated - Decree of Legal Separation
From married to widowed

1.
2.
4.

Death Certificate of spouse, if due to death of previously reported spouse

Court Order on the Declaration of Presumptive Death, if previously reported spouse is presumed dead

For reversion from married to single

1.

If legally married to previously reported spouse

a.1 Certificate of Finality of Annulment/Nullity or annotated Marriage Contract/Marriage Certificate, if due to annulled or void marriage
with previously reported spouse
a.2 Decree of Divorce and Certificate of Naturalization (granted before divorce) or its equivalent, if due to divorce with previously
reported spouse
a.3 Certificate of Divorce (OCRG Form No. 102), if due to divorce of Muslim member with previously reported spouse

2.

6.
7.

Updating of contact information - No required documents

Updating of bank information - any one (1) of the following (must be single savings or current account only):

1
2
3
8.

If not legally married to previously reported spouse

b.1 Certificate of No Marriage (CENOMAR) from Philippine Statistics Authority/National Statistics Office; and
b.2 Affidavit executed by the member attesting to the fact of the non-existence of marriage between him/her and the previously
reported spouse

Passbook
For ATM, machine-validated deposit slip showing the name and bank account number of member
Any document showing the member's name and bank account number (e.g., print-out of online banking transaction, bank statement)

Updating of member record status (from "Temporary" to "Permanent")

1.

Birth Certificate or in its absence, any of the following ID cards and/or documents:

1
2
3
4
5

Baptismal Certificate or its equivalent

Driver's License
Passport
Professional Regulation Commission (PRC) Card
Seaman's Book (Seafarer's Identification and Record Book)

2.

In the absence of the above ID cards and/or documents, any two (2) of the following, both with the correct name and at least one (1) with
date of birth:
1
Home
9
Philippine
Health
1
Alien Certificate of Registration
Development Mutual
Insurance Corporation (PHIC)
2
ATM Card (with cardholder's name)
Fund
(Pag-IBIG)
ID Card/ Member's Data
Transaction
Record
3
Bank Account Passbook
Card/Member's Data
10
Police Clearance
Form
4
Baptismal Certificate of child/ren or its equivalent
11
Postal ID Card
2
Homeowners
5
Birth Certificate of child/ren
Association ID Card
12
School ID Card
6
Certificate of Confirmation issued by National Commission on
3
ID Card issued by
13
Seafarer's Registration
Indigenous Peoples (formerly Office of Sourthern Cultural Community Local Government Units
Certificate
issued
by
and Office of Northern Cultural Community)
(LGUs)
(e.g.,
Philippine
Overseas
Barangay/Municipality/City)
Employment Administration
7
Certificate of Licensure/Qualification Documents from Maritime
(POEA)
4
ID
Card
issued
by
Industry Authority
14
Senior Citizen Card
professional
association
8
Certificate of Muslim Filipino Tribal Affiliation issued by National recognized by PRC
15
Student Permit issued
Commission on Muslim Filipinos
5
Life Insurance Policy
by Land Transportation Office
9
Company ID Card
(LTO)
6
Marriage
10
Court Order granting petition for change of name or date of birth
16
Taxpayer's
Contract/Marriage Certificate
Identification Number (TIN)
11
Credit Card
7
National Bureau of
Card
Investigation
(NBI)
12
Firearm License Card issued by Philippine National Police (PNP)
17
Transcript of Records
Clearance
13
Fishworker's License issued by Bureau of Fisheries and Aquatic 8
Overseas
Worker
18
Voter's
Identification
Resources (BFAR)
Welfare
Administration
Card/Affidavit/Certificate
of
14
Government Service Insurance System (GSIS) ID Card/ (OWWA) Card
Registration
Member's Record/Certificate of Membership

Health or Medical Card

I. Updating of dependent(s)/beneficiary(ies)

1.

For
reporting
of
new/additional
dependent(s)/beneficiary(ies)

1.

If
spouse
Marriage
Contract/Marriage Certificate or SS
Form E-4 of the spouse duly received
by the SSS where the name of the
member requesting the change is
reported as the spouse

2.

If
child/re
n - Birth
Certifica
te
or
Baptism
al
Certifica
te or its
equival
ent or

Decree
of
Adoptio
n

2.

For deletion
of previously
reported
dependent(s
)/beneficiary
(ies)

1.

If Spouse - any of the following,

whichever is applicable:

Decree of Legal Separation, if

legally separated with previously
reported spouse

Death Certificate of spouse, if

due to death of previously
reported spouse

Certificate of Finality of
Annulment/Nullity or annotated

Marriage Contract/Certificate, if
due to annulled or void marriage
with previously reported spouse

Court Order on Declaration of

Presumptive Death, if previously
reported spouse is presumed
dead

Decree
of
Divorce
and
Certificate
of
Naturalization
(granted before divorce) or its

equi
vale
nt, if
due
to
divo
rce
with
pre
viou
sly
rep

orte
d
spo
use

C
ertifi
cate
of
Divo
rce

(OCRG Form No. 102), if due to

divorce of Muslim member with
previously reported spouse

2.

If Parent/s - Death Certificate, if

previously reported parent/s is/are
already dead

3.

If other beneficiary/ies - No required

document/s