Republic of the Philippines

SOCIAL SECURITY SYSTEM

PERSONAL RECORD/UNIFIED MULTI-PURPOSE ID
(UMID) CARD APPLICATION (E-1/E-6)
MO0735IW202409238161 Date/Time Generated: 23 September 2024
10:00:30 PM
SS NUMBER
09-5230792-9
NAME
(LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)

DUGADUGA LARIENE ROSE LABUEN

FACTS OF BIRTH
DATE OF BIRTH (MMDDYYYY) PLACE OF BIRTH (CITY/MUNICIPALITY) (PROVINCE/STATE) (COUNTRY) SEX
11052004 POLOMOLOK SOUTH COTABATO PHILIPPINES FEMALE
FATHER'S NAME (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)
DUGADUGA MARTINES EJALON
MOTHER'S MAIDEN NAME (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)
LABUEN LOURDES RONQUILLO
DEMOGRAPHIC DATA
HOME ADDRESS (RM./FLR./UNIT NO. & BLDG. NAME or HOUSE/LOT NO. & BLK NO.) (STREET NAME) (SUBDIVISION)
PUROK MARIA ROSA
VILLAGE
(BARANGAY/DISTRICT/LOCALITY) (CITY/MUNICIPALITY) (PROVINCE) POSTAL CODE COUNTRY CODE
POBLACION POLOMOLOK SOUTH COTABATO 9504 0063
CIVIL STATUS HEIGHT (IN CENTIMETERS) WEIGHT (IN KILOGRAMS) DISTINGUISHING FEATURE/S NATIONALITY RELIGION
SINGLE 152 59 FILIPINO ROMAN
CATHOLIC
OTHER CARD APPLICANT DATA
TELEPHONE NUMBER (AREA CODE + TEL NO.) MOBILE NUMBER EMAIL ADDRESS
(0938) 289-2050 [email protected]
DEPENDENT(S)/BENEFICIARY/IES
SPOUSE (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX) DATE OF BIRTH (MMDDYYYY)

CHILDREN (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX) DATE OF BIRTH (MMDDYYYY)
1
2
3
4
5
OTHER BENEFICIARY/IES(If without spouse & child and parents are both deseased)
(LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX) RELATIONSHIP DATE OF BIRTH (MMDDYYYY)
1 DUGADUGA MITCHEL LABUEN Sister 08242003
FOR SELF-EMPLOYED/OVERSEAS FILIPINO WORKER/NON-WORKING SPOUSE
SELF-EMPLOYED (SE) OVERSEAS FILIPINO WORKER (OFW) NON-WORKING SPOUSE (NWS)

Profession/Business Foreign Address SS No./Common Reference No. of Working Spouse

Year Prof./Business Started

Monthly Income of Working Spouse (P)

Monthly Earnings Monthly Earnings Are you applying for membership in

the Flexi-Fund Program?

YES NO

PURPOSE OF APPLICATION
PURPOSE PROFESSION/BUSINESS ESTIMATED MONTHLY SALARY
FOR EMPLOYMENT / PRIOR
REGISTRANT
UMID CARD APPLICATION WITH ATM OPTION
UMID CARD AS ATM CARD (BANK NAME) (BANK BRANCH)

CERTIFICATION, DATA PRIVACY CONSENT AND AUTHORIZATION

1. I certify that the information provided are true and correct.
2. I hereby consent to:
• the collection, data capture, storage, biometric matching and the retention of my personal data for the generation/updating of my CRN, card
production and delivery, further processing and payment of my loans and SSS benefits;
• sharing of these data with SSS service providers to carry out the purposes stated above; and
• disposal of this application in the manner consistent with the Data Privacy Act.
3. I trust that all these data shall be kept confidential by SSS and its service providers and my bank.
4. I further give my consent to SSS to share necessary data with my chosen bank for the generation of bank account number, crediting of loan and
benefit proceeds to the account number and payment of said loan and benefit proceeds. For this purpose, I consent for the sharing of my bank
account number with SSS.
 INSTRUCTIONS

1. Fill out this form in one (1) copy.

2. Erasures/alterations are not encouraged. However, if necessary, such will be limited up to two (2) erasures/alterations only.
Always affix initials on all erasures/alterations of this form.
3. Place a checkmark on the applicable box.
4. Always indicate "N/A" or "Not Applicable", if the required data is not applicable.
5. Indicate the home address. If permanent home address is in the province but working in Metro Manila during weekdays or
working abroad, indicate the provincial address instead of the Metro Manila address.
6. Write the "HEIGHT" in centimeters and "WEIGHT" in kilograms.
To convert: 1 ft = 30.48 cm 1 in = 2.54 cm 1 lb = 0.4536 kg
7. Limit the distinguishing features to those that can be found on the face such as "mole under the right eye" and "mole or
birth mark on the left cheek/forehead".
8. Always indicate the following mandatory information:
• Country of place of birth, if born outside the Philippines
• Mobile number, if applied locally*
• Email address, if applied abroad*
* if card applicant cannot provide the required mobile number/email address, indicate the card applicant's immediate family
member's mobile number/email address where SSS can communicate with the card applicant.
9. For all types of card replacement, pay the required fee at any SSS branch office/accredited bank/collecting agent. Write the
Special Bank Receipt (SBR)/Receipt Number/Transaction Reference Number on the field provided and submit this form
together with the required document/s and proof of payment to the nearest SSS branch office.
10. For card replacement due to unclaimed UMID cards beyond five (5) years, a replacement fee and biometric data re-capture is required.
11. Submit this form to the nearest SSS branch with the following required documents (use the table Documentary Requirements
Guide).
DOCUMENTARY REQUIREMENTS GUIDE
IDENTIFICATION REQUIREMENTS (Present the original) IDENTIFICATION REQUIREMENTS (Present the original)
A. Primary ID card/document [any one (1) of the following]: A. For card replacement due to amendment of
1. Unified Multi-Purpose ID Card data/authenticating finger
2. Social Security Card Previously issued SS digitized ID or UMID card of
3. Alien Certificate of Registration the card applicant
4. Driver's License Proof of payment
5. Firearm Registration B. For card replacement due to lost SS digitized ID or
6. License to Own and Possess Firearms UMID Card Duly notarized Affidavit of Loss
7. National Bureau of Investigation (NBI) Clearance Proof of payment
8. Passport C. For card replacement due to non-receipt of
9. Permit to Carry Firearms Outside of Residence UMID Card Duly notarized Affidavit of Non-
10. Postal Identity Card Receipt of Card
11. Seafarer's Identification & Record Book (Seaman's Notice/Email from Identity Management
Book) Department (IMD) that the courier lost/was not
12. Voter's ID Card able to deliver the UMID Card Proof of payment
B. Any two (2) other ID cards/documents, both with C. For card replacement due to damaged UMID Card, UMID
signature and at least one (1) with photo (In absence of a Card as ATM Card and other reason/s
primary card). Please specify. Proof of payment

12. Observe proper attire when applying for a UMID card.

DOs DONTs
• Collared shirt/blouse is encouraged • Wearing of the following:
• Face and neck should be free a. For Male - undershirt/"sando" and/or earrings d. Metal piercing in any part of
from bandage or accessories the face
b. For Female - dangling or overstated earrings e. Head gear
c. Eyeglasses and/or colored contact lenses f. Sunglasses
Unified Multi-Purpose ID (UMID) Card Application Page 2

REMINDERS

1. Card applicants who chose to enroll their UMID Card as ATM card at point of card application shall claim the same at the
specified bank's branch or kiosk within thirty (30) days upon receipt of SMS notification from SSS.
2. For regular UMID Card, the default mode of issuance is pick-up at the SSS branch office where card application was made.
3. UMID Cards for pick-up at SSS Offices where card application was filed, shall be claimed within sixty (60) days from receipt of
SMS notification from SSS. Otherwise, unclaimed UMID Cards within the 60-days claiming period shall be verified thru IMD or
SSS hotline. Unclaimed UMID Cards beyond five (5) years shall be shredded or destroyed.
4. To verify the status of your UMID Card application, you may reach us at 920-6401 local 5714 or email at [email protected].
5. Card applicants shall be required to verify the status/availability of their UMID Cards if with change of mobile number after
the card application was made or non-receipt of SMS notification from SSS within thirty (30) days from card application.
6. Unsuccessfully delivered UMID Cards (RTS) will be sent to the SSS branch office where biometric data capture was made.