E4 Form Sss – Fill Out and Use This PDF

		Republic of the Philippines
	E-4	SOCIAL SECURITY SYSTEM
		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

NAME	(LAST NAME)	(FIRST NAME)	(MIDDLE NAME)	(SUFFIX)
ADDRESS		(RM./FLR./UNIT NO. & BLDG. NAME)	(HOUSE/LOT & BLK NO.)	(STREET NAME)

B. DATA CHANGE/CORRECTION/UPDATING

(A person who registered with the	SIGNATURE OVER PRINTED NAME OF WORKING SPOUSE
SSS for the first time as a
prospective employee. )

Due to to Re-marriage

C. CORRECTION OF DATE OF BIRTH

D. CORRECTION OF SEX

E. 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
			Married to Widowed
			Reversion from Married to Single
F.
	UPDATING OF CONTACT INFORMATION
			Address	Telephone Number		E-mail Address		Mobile/Cellphone Number
G.	UPDATING OF BANK INFORMATION
				Bank Name		Bank Branch		Account Number

Benefits (Sickness/

Maternity/Partial Disability)

Loans

PESO Fund

H. UPDATING OF MEMBER RECORD STATUS (From "Temporary" to "Permanent") - please indicate submitted documents

I. UPDATING OF DEPENDENT(S)/BENEFICIARY(IES) (Please check the appropriate box. If more than 3, use other page "Instructions" portion.)

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

Page 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).

A.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:

a.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

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

3.Required additional ID cards and/or documents for the following cases:

a.If for correction of date of birth and submitted birth certificate is registered after the 55th birthday - two (2) ID cards and/or documents in Item 2.b above.

b.If for correction to totally different name/middle name (except if due to naturalization) - Joint Affidavit of two (2) persons who have personal knowledge of the facts and circumstances on the use of the different name/middle name stating therein that the two

(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:

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

‒Certificate of Naturalization issued by the Philippine Department of Foreign Affairs

‒Identification Certificate issued by the Philippine Bureau of Immigration

‒Any foreign government issued ID cards and/or documents showing the new name (e.g., Passport, Driver's License)

b.Correction of name due to re-marriage - new Marriage Contract/Marriage Certificate and any of the following, whichever is applicable:

‒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 equivalent, if due to divorce with previously reported spouse

‒Certificate of Divorce (OCRG Form No. 102), if due to divorce of Muslim member with previously reported spouse D. Correction of sex - any of the following, whichever is applicable:

‒Birth Certificate

‒Passport

‒Member's copy of Personal Record (SS Forms E-1, RS-1, OW-1, NW-1) duly received by the SSS where the correct sex is indicated

‒Court 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 NAMESIGNATUREDATE

If member cannot sign, affix fingerprints (please see Instruction no. 5).

Below are the witnesses to fingerprinting:

1)

PRINTED NAME

SIGNATURE

DATE

ADDRESS & CONTACT NUMBER

2)

PRINTED NAME

SIGNATURE

DATE

RIGHT THUMB

RIGHT INDEX

ADDRESS & CONTACT NUMBER

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

DATE & TIME

BRANCH

PROCESSED BY

ENCODED BY

SIGNATURE OVER PRINTED NAME

DATE & TIME

SIGNATURE OVER PRINTED NAME

DATE & TIME

REVIEWED BY

APPROVED BY

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:

a.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

b.Filed by employer or company representative or household employer

1.SS card or UMID card or two (2) ID cards of the member, both with signature and one (1) with photo; and

2.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:

a.Filed by member

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

b.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 (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

4.

New/Additional

Deletion

5.

New/Additional

Deletion

Page 2 of 2

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

1.From single to married - Marriage Contract/Marriage Certificate

2.From married to legally separated - Decree of Legal Separation

3.From married to widowed

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

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

4.For reversion from married to single

a.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

b.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

F.Updating of contact information - No required documents

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

‒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)

H.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:

‒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

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

a.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

b.If child/ren - Birth Certificate or Baptismal Certificate or its equivalent or Decree of Adoption

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

a.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 equivalent, if due to divorce with previously reported spouse

‒Certificate of Divorce (OCRG Form No. 102), if due to divorce of Muslim member with previously reported spouse

b.If Parent/s - Death Certificate, if previously reported parent/s is/are already dead

c.If other beneficiary/ies - No required document/s