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 COMMON REFERENCE NUMBER (IF ANY) DATE OF BIRTH (MMDDYYYY) TAX IDENTIFICATION NUMBER (IF ANY)
NAME (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)
ADDRESS (RM./FLR./UNIT NO. & BLDG. NAME) (HOUSE/LOT & BLK NO.) (STREET NAME)
(SUBDIVISION) (BARANGAY/DISTRICT/LOCALITY) (CITY/MUNICIPALITY) (PROVINCE) ZIP CODE
TELEPHONE NUMBER (AREA CODE + TEL. NO.) MOBILE/CELLPHONE NUMBER E-MAIL ADDRESS
FOREIGN ADDRESS (IF APPLICABLE) COUNTRY ZIP CODE
B. DATA CHANGE/CORRECTION/UPDATING
A. CHANGE OF MEMBERSHIP TYPE
FROM TO TO (Option for Prior Registrant Only)
Employed Self-Employed (Please fill-out the details below.) Non-Working Spouse (Please fill-out the details below.)
Voluntary Profession/Business SS No./CRN of Working Spouse
Overseas Filipino Worker Year Profession/Business Started Monthly Income of Working Spouse (P)
Non-Working Spouse (NWS) Monthly Earnings (P) I AGREE WITH MY SPOUSE'S MEMBERSHIP WITH SSS.
Prior Registrant
(A person who registered with the SIGNATURE OVER PRINTED NAME OF WORKING SPOUSE
SSS for the first time as a
prospective employee. )
FROM TO
B. CORRECTION OF NAME
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)
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)
New/Additional
1. Deletion
New/Additional
2. Deletion
New/Additional
3. Deletion
Perforate
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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
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 Perforate here
SIGNATURE OVER PRINTED NAME DATE & TIME BRANCH
PROCESSED BY Perforate BY
ENCODED here
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)
New/Additional
1. Deletion
New/Additional
2. Deletion
New/Additional
3. Deletion
New/Additional
4. Deletion
New/Additional
5. Deletion
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