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Republic of the Philippines
SOCIAL SECURITY SYSTEM
CONTRIBUTIONS
PAYMENT FORM
|CON-01279 (11-2016)
JPLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT|
[THis FORM. PRINT ALL INEORMATION IN CAPITAL LETTERS AND USE|
JBLACK INK ONLY,
PAYOR’s COPY
TOE FLED OUT BY EMPLOYER
"TOBE FILLED OUT BY INDIVIDUAL PAYOR
Cl business 1D Househots
Di SetEmpioyed
1D Vountary
Tl oFW (Foreign Adis - Cy. Country )
‘Ci non-orking Spouse
Cl FamerFisherman
[EMPLOYER NOWEER
ISS NUMBER wwomn [COMNON REFERENCE NUMBER jaw vsoaTa
SNPLOVER NAME
INANE
TOBE FILLED OUT BY EW
[ADDRESS TORR RTH OS TELS SL HOT
PLOYER AND INDIVIDUAL PAYOR
[aP CODE [TAX IDENTIFICATION NUMBER ay
[TELEPHONE NUMBER ascr cases) | NOBILETCELLPHONE NUMBER
[EWA ADDRESS
frre!
(aa "APPLICABLE PERIOD ‘35 CONTRIBUTION
MONTH year _| ‘
"EC CONTRIBUTION TOTAL
anuary e
February
arch
oo
May
uy
August
September
‘October
Rovember
jOTAL AMOUNT OF PAYMENT.
FORM OF PAYMENT
cash
G Postal Money Order
Dcheek
‘Check Number
Check Date
‘Bank & Branch Name
"AMOUNT PAID INFIGURES
2
TOTAL AMOUNT PAID IN WORDS
PADEY
TOTAL AMOUNT PAID e
PRINTED NAME ‘SIGHATORE
| hereby declare, for purposes of Sec. 1A of the Socal Securty
"aff under te penates of perury, that the declaration has been
‘DECLARATION OF EARNINGS OF INDIVIDUAL PAYOR
(@ ____ae my monthly earings, wich shallbe the basis of my monthly salary cred to be effective unl revised my next dedaration.
Law the amount of
‘made in good fat, and tothe best of my knowledge and bel, ste and
PRINTED WANE OF MEMBER
SIGNATURE OF WEWEER, INSTRUCTIONS
1, Always: indicate "NIA" or "Not Applicable’, f the required data isnot appicabe.
2. Pay through ary ofthe flowing:
'SSS Branch with Talleing Faciites
Accredited Barks
Pos! Office
Bayad Centers
SM Business Centers
3. Make al checks and postal money orders payable to SSS. Fill out property the check dotals in the “Form of Payment” portion.
For Employer
‘Accomplish appropriate boxes as follows:
‘2, For business employer
= employer number, business name, business address and 12-. For Overseas Filing Worker [OFW
* Contributions for January to December of a glven year may be paid anytime within tha same year.
+ Contributions for October to December ofa given year may also be paid unti 31 January ofthe succeeding year.
In case the payment deadine fals on a Saturday, Sunday or holiday, payment may be made on the next working day, Otherwise,
late contribution payments shal be applied prospectively.
3, Fil out the folowing portons:
{8 "SS" column only ofthe ‘PAYMENT DETAILS" portion (need not fl out the "Total column,
. “Declaration of Eamings of Individual Payor” portion f you want to change your monthly salary credit (MSC) to more than
two (2) Salary brackets higher or lower than your present MSC.
However, the following shall be observed:
+ For OFW, the minimum MSC shal be P5,000.00. Hence, any change lower than the minimum MSC shall not be allowed.
+ Whore the present MSC Is more than 10,000.00 and the age of the member Is 5S years old or older, the allowed
Increase is only one 1) salary bracket recardiess of whether the supporting documents are submited or not.
¢EMINDE!
1 The total contributions paid by the Employer inthis payment form includes the Social Secutty contributions shared by both the
employer and employee plus the EC contributions shouldered solely by the employer, in accordance with the SSS monthly
‘contibution schedule
‘You may also visit the SSS Website at www. sss. gou-ph for other payment facies,
ep al your validated payment forms for future reference,
