SS NUMBER NAME OF MEMBER
(SURNAME)
ADDRESS
(NUMBER, STREET AND SUBDIVISION)
(BARANGAY) (TOWN/DISTRICT) (CITY/PROVINCE)
POSTAL CODE
SIGNATURE OVER PRINTED NAME DATE
WITNESSES TO FINGERPRINTS
PART I - MEMBER'S INFORMATION
MEMBER'S CERTIFICATION
I certify that this is my ________ pregnancy and my expected date of delivery is on ____________________.
(GIVEN NAME (MIDDLE NAME)
DATE OF BIRTH
(MMDDYYYY)
TIN
E-MAIL ADDRESS (if any)TELEPHONE/MOBILE NUMBER
e
u
c o
t
e
nes
SOCIAL SECURITY SYSTEM
MATERNITY NOTIFICATION
Please read instructions and reminders below before filling up this form. Print all information in black ink only.
I certify that the above information is true and correct.
(If member cannot sign, fingerprints should be witnessed by two persons)
Please affix signature over printed name and indicate date
SMD-0002
01-2009
1)
2)
EMPLOYER NUMBER
ADDRESS
POSTAL CODE
PROCESSED BY:
(NUMBER, STREET AND SUBDIVISION)
NAME OF EMPLOYER/REGISTERED BUSINESS NAME
PART II - EMPLOYER'S INFORMATION (FOR EMPLOYED)
(BARANGAY)
EMPLOYER/AUTHORIZED REPRESENTATIVE
SIGNATURE OVER PRINTED NAME OF
EMPLOYER'S CERTIFICATION
OFFICIAL DESIGNATION
I certify that the above-member is pregnant and expected to give birth on the date stated above.
TELEPHONE/MOBILE NUMBER
INSTRUCTIONS AND REMINDERS
RECEIVING BRANCHSIGNATURE OVER PRINTED NAME
DATE
(TOWN/DISTRICT)
IDs presented
No ID presented
(CITY/PROVINCE)
I certify that the above information is true and correct.
SS Card
Two (2) valid IDs
PART III - FOR SSS USE
DATE
RIGHT THUMB RIGHT INDEX
1.
2.
3.
4.
5. If employed, full payment of the Maternity Benefit shall be advanced by the employer within thirty (30) days from the filing of maternity
leave application.
Receipt of Maternity Notification form does not guarantee payment of the Maternity Benefit. Payment of benefit will be based on existing
policies and guidelines.
The employer in turn, shall submit the Maternity Notification form to its servicing branch immediately after the receipt of notification from
the employee.
Upon filing of the Maternity Benefit Application, the duly stamped "Received" Maternity Notification form shall be attached to the maternity
benefit application form
A member shall submit the Maternity Notification to her employer, if employed, or to the SSS branch nearest her residence, if separated
from employment/self-employed/voluntary/OFW/non-working spouse, at least sixty (60) days from the date of conception but not later
than the date of delivery.
