Template 2.
Petition for Declaration of Spouse’s Dependency for Support Upon
Deceased Member or Petition for Resumption of the Surviving
Spouse’s Pension Benefit
Republic of the Philippines
SOCIAL SECURITY COMMISSION
Makati City
___________________________,
Petitioner,
- versus - SSC CASE NO. _________
SOCIAL SECURITY SYSTEM,
Respondent.
x--------------------------------x
PETITION
COMES NOW Petitioner (full name of petitioner), by counsel, and unto this
Honorable Court, most respectfully states that:
1. PERSONAL CIRCUMSTANCES OF THE PARTIES:
1.1. PETITIONER
Name of Petitioner __________________________________________________
Sex ____ Age ____ Civil Status _________
Petitioner’s home address
City ______________________________________________________________
______________________________________________ Zip Code ___________
Province, if applicable_______________________________________________
______________________________________________ Zip Code ___________
Telephone No. ____________________ Cellphone No. _________________
Place of Work _____________________________________________________
Telephone No. ____________________ Cellphone No. _________________
If petitioner is assisted by counsel or law student pursuant to the
requirements under this Commission’s Revised Rules of Procedure
Petitioner’s Counsel or assisting law student
Name ____________________________________________________________
Firm Name/Law school clinical legal education program
_________________________________________________________________
Mailing Address ____________________________________________________
__________________________________________________________________
Page 2 of 5
Email Address ________________________________________
Tel/Cel/Fax Nos. _____________________________________
PTR No. _________________ Date/Place of Issue________________
Roll No. _________________
IBP No. _________________ Lifetime
Date/Chapter _________________
MCLE Compliance No. ______________
Exemption _________________
Other Compliances ________________________________________
1.2. RESPONDENT
Respondent Social Security System is a corporate body created by law pursuant to
RA 1161, as amended, with principal office located on East Avenue, Diliman,
Quezon City, Metro Manila
2. STATEMENT OF FACTS AND OTHER CAUSE/S OF ACTION
2.1. Petitioner is the legitimate surviving spouse of deceased SS member
(name of deceased member) with SS No. _____________________, entitled to
the SS death benefit under Section 12-B (d)1 or Section 132 of the Social Security
Act of 1997 both in relation to 8 (e) (1) and (k)3 thereof. Further, in accordance
with Art. 68 and 195 (1) of the Family Code4, petitioner is considered as
dependent upon deceased member for support.
Evidencing the fact of petitioner’s marriage with deceased member are the
following:
Marriage Contract (Annex “__”)
Petitioner’s Advisory on Marriages issued by the Philippine Statistics
Authority (PSA) (Annex “__”)
Member’s Advisory on Marriages issued by the PSA (Annex “__”
1
SEC. 12-B. Retirement Benefits. – (d) Upon the death of the retired member, his primary beneficiaries as
of the date of his retirement shall be entitled to receive the monthly pension: xxx
2
SEC. 13. Death Benefits. – Upon the death of a member who paid at least thirty-six (36) monthly
contributions prior to the semester of his death, his primary beneficiaries shall be entitled to the monthly
pension: Provided, That if he has no primary beneficiaries, his secondary beneficiaries shall be entitled to a
lump sum benefit equivalent to thirty-six (36) times the monthly pension. If he has not paid the required
thirty-six (36) monthly contributions, his primary or secondary beneficiaries shall be entitled to a lump sum
benefit equivalent to the monthly pension times the number of monthly contributions paid to the SSS or
twelve (12) times the monthly pension, whichever is higher (Social Security Act of 1997)
3
SEC. 8. Terms Defined. – For the purpose of this Act, the following terms shall, unless the context
indicates otherwise, have the following meanings:
xxx
(e) Dependents – The dependents shall be the following:
“(1) The legal spouse entitled by law to receive support from the member;
xxx
(k) Beneficiaries – The dependent spouse until he or she remarries, the dependent legitimate,
legitimated or legally adopted, and illegitimate children, who shall be the primary beneficiaries of
the member: xxx
4
Art. 68. The husband and wife are obliged to live together, observe mutual love, respect and fidelity, and
render mutual help and support.
Art. 195. Subject to the provisions of the succeeding articles, the following are obliged to support each
other to the whole extent set forth in the preceding articles:
(1) Spouses; xxx (Family Code of the Philippines)
Page 3 of 5
Others, specify_______________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
2.2. SSS member (name of deceased member) died on (date of death), as
shown in the attached:
Death Certificate (Annex “__”)
Court Order on the Declaration of Presumptive Death, if member
is presumed dead (Annex “__”)
Others, specify _______________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
2.3.1. Did you file a death claim on account of member’s death or a
reconsideration of the revocation/suspension of monthly pension with the SSS?
Yes No
2.3.2. If NO, why did you file a case with this Commission without first filing a
claim with the SSS? (State reason/s below)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2.3.3. If YES, what is the action taken by the SSS? (Please attach letter of
denial/revocation/suspension of pension)
granted
denied
still pending
on the ground/s of:
remarriage of petitioner when member was still alive or after the
member’s death
Cohabitation of petitioner with another man/woman when member was
still alive or after the member’s death
Petitioner’s alleged abandonment of the member
Petitioner’s alleged attempt on member’s life
Being separated from the member since (date of separation)
Others, specify _______________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
2.3.4. What is the SSS’ written action in denying your claim for member’s death
benefit or your reconsideration of the revocation/suspension of monthly pension?
denial by the SSS President
denial by the Manager or Officer-in-Charge or authorized personnel of the
SSS Department/Branch/Representative Office concerned
Certification from the Benefit Appeals Review Committee
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2.3.5. Is there truth on the ground of the SSS in the denial of your claim or
revocation/suspension of your monthly pension?
YES, but I am still entitled to member’s death benefit as his/her dependent
legitimate spouse based on the following: (State reason/s with attached
documents to prove the same)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
NO, as shown in the following attached documents, I remained the
dependent legitimate spouse of deceased member during his/her lifetime and even
after his/her death because I did not:
remarry another during the lifetime of member, as shown in the
Advisory on Marriage issued by the PSA
others, specify ___________________________________
_______________________________________________
_______________________________________________
cohabit with another man/woman when member was alive and
until the present, as supported by the
Affidavit of Disinterested Persons of no cohabitation
others, specify ___________________________________
________________________________________________
________________________________________________
abandon the member, as supported by the
Affidavit of Disinterested Persons of no abandonment
others, specify ___________________________________
________________________________________________
________________________________________________
attempt on member’s life, as supported by the
Affidavit of Disinterested Persons of no attempt on
member’s life
others, specify ___________________________________
________________________________________________
________________________________________________
separate with member during his/her lifetime, as supported by the
Affidavit of Disinterested Persons of no separation
others, specify ___________________________________
_______________________________________________
_______________________________________________
Others, specify and attach documentary evidence to support the
same _________________________________________________
______________________________________________________
______________________________________________________
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2. REMEDY OR RELIEF SOUGHT
WHEREFORE, petitioner respectfully prays that judgment be issued declaring
petitioner (state name of petitioner) to be deceased member (state deceased member’s
name)’s dependent legitimate surviving spouse and primary beneficiary, entitled to the
survivor’s pension benefit provided under the Social Security Law, as amended, and
directing respondent SSS to:
resume the survivor’s pension benefit from the time it was
revoked/suspended on (state date of revocation/suspension)
immediately pay the petitioner the survivor’s pension benefit accruing
from the death of SSS member (state name of deceased member)
Petitioner prays for such other reliefs as may be just and equitable in the premises.
(place signed), Philippines, (date signed).
(Name of petitioner and his/her signature or name/s and signature/s of his/her counsel
or the assisting law student and his/her supervising attorney)
VERIFICATION AND CERTIFICATION
AGAINST FORUM SHOPPING
