Republic of the Philippines

SOCIAL SECURITY SYSTEM

_______________________________ ( Branch Name)

(10-2008) ____________________________________ (Address)

(Name of Claimant)

(SS No.)

(Address) (Name of Member)

Checklist for Retirement Claim Benefit ScreenerCode

( ) Retirement Claim Application (RCA) Form

( ) Certification of Separation from the last employer, if certification portion of the RCA was not accomplished by last employer

( ) Affidavit of Separation (SS Form E-417), in the absence of employer's certification of separation (if last employer no longer exist/if member's residence is far from the

address of the last employer within/outside the Philippines)

( ) Certification of non-renewal of professional license/business permit from applicable offices for member less than 65 years old (e.g., Business Permit and

Licensing Office, Professional Regulations Commission etc.) or certificate of cessation of business issued by the barangay of your locality and affidavit of cessation of business/practice of profession.

( ) Certification from the company that you are an underground mineworker indicating the period of employment and supported by your job description.

( ) Affidavit of no earnings from self-employment for member less than 65 years old, accompanied by a certification of cessation of business issued by the barangay of

your locality.

( ) Marriage Contract

( ) Birth/Baptismal Certificate of dependent children

( ) Proof of relationship with SSS member such as record of birth, a statement before a court of record or any document acknowledging the relationship, for illegitimate

minor children

( ) Medical Certificate of incapacitated member issued by the attending physician

( ) Medical Certificate of incapacitated child issued by the attending physician

( ) Application for Guardianship (SS Form CLD-15)

( ) Guarantor’s Form (SS Form BPN-107)

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Checklist for Retirement Claim Benefit ScreenerCode

( ) Affidavit of Guardianship (SS Form CLD-1.1B)

( ) Joint affidavit of two (2) disinterested persons attesting to the fact, if such is the case, that _____________________ and _________________________ are

one and the same person, stating therein the correct name.

( ) Latest 1 x 1 picture of claimant

( ) Original and photo copy of claimant's Social Security Card, Passport, PRC Card, Seaman's Book, Driver's License or any two valid Ids, at least one with photo(e.g., Company ID, Senior Citizen's ID, Police or NBI Clearance, Voter's ID etc.)

( ) Passbook/ATM card with name or copy of validated deposit slip (original and photocopy) or Cash Card Enrollment Form, if pension

( ) Others _________________________________________________________________ _______________________________________________________________________

_________________________________________________________________ _________________________________________________________________ _________________________________________________________________

FOR SSS USE

SCREENED BY: SC01

SCREENED BY: SC02

SIGNATURE OVER PRINTED NAME DATE

SIGNATURE OVER PRINTED NAME DATE

SCREENED BY: SC03

SCREENED BY: SC04

SIGNATURE OVER PRINTED NAME DATE

SIGNATURE OVER PRINTED NAME DATE

NOTE: 1. Birth certificate and marriage contract should be duly registered with the National Statistics Office/Local Civil

Registrar Office and baptismal certificate by the Parish/Church. 2. In refiling, please attach this letter to the retirement claim application.