PPS-HEUR1 FORM (V.

1)
SSS HOUSEHOLD EMPLOYER ID NUMBER
NAME
SEX (Kasarian) TAX IDENTIFICATION NUMBER (IF ANY)
ADDRESS UNIT/RM./FLR. NO. BUILDING NAME LOT/BLK./HOUSE NO. STREET NAME SUBDIVISION
(Tirahan) (Bilang ng Yunit at Palapag) (Pangalan ng Gusali) (Bilang ng Lote, Bloke, Bahay) (Kalye) (Subdibisyon)
BARANGAY/DISTRICT MUNICIPALITY/CITY PROVINCE/REGION
ZIP CODE
(Barangay/Distrito) (Munisipyo/Syudad) (Probinsya/Rehiyon)
TELEPHONE NUMBER (AREA CODE+TEL. NO.) MOBILE/CELLPHONE NUMBER E-MAIL ADDRESS NUMBER OF KASAMBAHAY/S
(Bilang ng Kasambahay)
(Ako ay nagpapatunay na ang aking mga isinaad sa itaas ay totoo at tama na nararapat para ako ay ma-rehistro bilang Household Employer sa programa ng Pag-IBIG, PhilHealth at SSS.)
RECEIVED BY Pag-IBIG PHILHEALTH SSS EVALUATED BY FOR PHILHEALTH USE
1. If filed/submitted personally by the Household Employer, no supporting document is required to be submitted.
2. If duly accomplished Form is filed/submitted through an Authorized Representative of the Household Employer, presentation of the following
is required:
- Letter of Authorization from Household Employer
- Valid ID of the Household Employer
- Valid ID of the Authorized Representative
3. Update/s or Change/s in the Employer Information should be submitted to each of the 3 Agencies - Pag-IBIG, PhilHealth and SSS.
Republic of the Philippines
NAME EXTENSION
(Gitnang Pangalan)
SIGNATURE OVER PRINTED NAME DATE & TIME
CHECK IF NO MIDDLE NAME
(I-tsek ang kahon kung walang
gitnang pangalan)
SIGNATURE OVER PRINTED NAME OF HOUSEHOLD EMPLOYER
INSTRUCTIONS
DATE / TIME
SIGNATURE OVER PRINTED NAME OF
AUTHORIZED OFFICER OF RECEIVING AGENCY
PLEASE READ THE INSTRUCTIONS BELOW BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK OR BLUE INK
.ONLY. (Basahin ang mga Instructions sa ibaba ng Form bago ito sulatan. Isulat ang lahat ng impormasyon sa MALALAKING TITIK at gumamit lamang ng ITIM o ASUL na
. tinta.)
Pag-IBIG HOUSEHOLD EMPLOYER NUMBER/
REGISTRATION TRACKING NUMBER (RTN)
PHILHEALTH EMPLOYER NUMBER (PEN)
MIDDLE NAME
PART II - B. CERTIFICATION
SIGNATURE OVER PRINTED NAME
THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE
I hereby certify that the information supplied above are true and correct for the purpose of my registration in the three (3) social security
agencies of the Philippine Government, namely, Pag-IBIG, PhilHealth & SSS, as Household Employer.
LAST NAME
(Apelyido)
FIRST NAME
(Ex. Jr. / II)
MALE
(Lalake)
FEMALE
(Babae)
DATE
(Pangalan)
HOUSEHOLD EMPLOYER
UNIFIED REGISTRATION FORM
(Pursuant to R.A. 10361 or the "Batas Kasambahay")
PART II - A. PERSONAL INFORMATION
BRANCH DATE & TIME
DATE OF BIRTH (Araw ng Kapanganakan)
Month Day Year
This is to certify that a Letter of Authorization from the Household Employer was presented and that the signature was verified based on the
valid ID presented.
PART III - TO BE FILLED OUT BY Pag-IBIG/PHILHEALTH/SSS
PART IV - CERTIFICATION BY RECEIVING AGENCY (If filed through an Authorized Representative)
PART I - PLEASE INDICATE YOUR EMPLOYER / MEMBERSHIP NUMBER IF ALREADY REGISTERED
(Paki lagay ang inyong numero sa Pag-IBIG, PhilHealth or SSS kung myembro na)
PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK OR BLUE INK ONLY.
Pag-IBIG Household Employer ID Number PHILHEALTH Employer Number (PEN) SSS Household Employer ID Number INITIAL LIST (ATTACH WITH HOUSEHOLD EMPLOYER UNIFIED REGISTRATION FORM (PPS-HEUR1))
SUBSEQUENT LIST
EMPLOYER NAME
Pag-IBIG MID NO./RTN PHILHEALTH IDENTIFICATION NO. (PIN) SOCIAL SECURITY (SS) NO. 1. KASAMBAHAY NAME
(Pangalan ng Kasambahay)
DATE OF BIRTH DATE OF EMPLOYMENT DATE OF SEPARATION MONTHLY WAGE/SALARY/ EARNINGS RELATIONSHIP TO HOUSEHOLD EMPLOYER
(MM-DD-YYYY) (MM-DD-YYYY) (MM-DD-YYYY) (Buwanang Sweldo) (Relasyon sa Household Employer)
- - - - - -
Pag-IBIG MID NO./RTN PHILHEALTH IDENTIFICATION NO. (PIN) SOCIAL SECURITY (SS) NO. 2. KASAMBAHAY NAME
(Pangalan ng Kasambahay)
DATE OF BIRTH DATE OF EMPLOYMENT DATE OF SEPARATION MONTHLY WAGE/SALARY/ EARNINGS RELATIONSHIP TO HOUSEHOLD EMPLOYER
(MM-DD-YYYY) (MM-DD-YYYY) (MM-DD-YYYY) (Buwanang Sweldo) (Relasyon sa Household Employer)
- - - - - -
Pag-IBIG MID NO./RTN PHILHEALTH IDENTIFICATION NO. (PIN) SOCIAL SECURITY (SS) NO. 3. KASAMBAHAY NAME
(Pangalan ng Kasambahay)
DATE OF BIRTH DATE OF EMPLOYMENT DATE OF SEPARATION MONTHLY WAGE/SALARY/ EARNINGS RELATIONSHIP TO HOUSEHOLD EMPLOYER
(MM-DD-YYYY) (MM-DD-YYYY) (MM-DD-YYYY) (Buwanang Sweldo) (Relasyon sa Household Employer)
- - - - - -
DATE
RECEIVED BY Pag-IBIG PHILHEALTH SSS
This is to certify that a Letter of Authorization from the Household Employer was presented and that the signature was verified based on the valid ID presented.
OF RECEIVING AGENCY
SIGNATURE DATE & TIME
TOTAL NUMBER OF
KASAMBAHAY/S
FOR THIS REPORT
SIGNATURE OF HOUSEHOLD EMPLOYER
BRANCH DATE & TIME SIGNATURE OVER PRINTED NAME
PART III - TO BE FILLED OUT BY Pag-IBIG/PHILHEALTH/SSS
THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE
PART I - EMPLOYER INFORMATION
PART II - KASAMBAHAY INFORMATION
FIRST NAME
CHECK IF NO MIDDLE NAME
(I-tsek ang kahon kung walang
gitnang pangalan)
CHECK IF NO
MIDDLE NAME
(Pangalan)
LAST NAME
PRINTED NAME OF AUTHORIZED OFFICER
PART IV - CERTIFICATION (If filed through an Authorized Representative)
PAGE _____ OF _____ PAGE/S
(Use extra sheet if necessary)
I certify that the information provided in this form are true and correct.
NAME EXTENSION MIDDLE NAME
CHECK IF NO
MIDDLE NAME
MIDDLE NAME
(Apelyido)
NAME EXTENSION
Republic of the Philippines
HOUSEHOLD EMPLOYMENT UNIFIED REPORT FORM
(Pursuant to R.A. 10361 or the "Batas Kasambahay")
TYPE OF
REPORT
FIRST NAME
(Ex. Jr. / II)
(Ex. Jr. / II) (Gitnang Pangalan)
LAST NAME
LAST NAME
MIDDLE NAME
(Apelyido)
(Apelyido) (Pangalan)
PPS-HEUR2 FORM (V.1)
CHECK IF NO
MIDDLE NAME
(Apelyido) (Pangalan) (Ex. Jr. / II) (Gitnang Pangalan)
(Gitnang Pangalan)
LAST NAME FIRST NAME NAME EXTENSION
(Gitnang Pangalan)
NAME EXTENSION FIRST NAME
(Ex. Jr. / II)
MIDDLE NAME
(Pangalan)
1. This form is not applicable for reporting of Family Driver.
2. A household employer who is not yet registered with any of the agencies must submit this form in triplicate (3) copies together with the Household Employer Unified Registration
Form (HEUR1), in 3 copies also, to any service office of Pag-IBIG, PhilHealth or SSS.
3. An employer already registered with Pag-IBIG, SSS and PhilHealth will submit this form in triplicate (3) copies to any office of the said agencies to report (a) newly hired employee/s
or (b) to report a separated/terminated employee/s.
4. ALL FIELDS SHALL BE FILLED-OUT CORRECTLY BY THE HOUSEHOLD EMPLOYER, except Part III & IV.
5. If duly accomplished Form is filed/submitted through an Authorized Representative of the Household Employer, presentation of the following is required:
- Letter of Authorization from Household Employer
- Valid ID of the Household Employer
- Valid ID of the Authorized Representative
6. For SSS purposes only:
(a) Household Employer should submit to SSS the Specimen Signature Card (SSS Form L-501) which is available at all SSS Branches and Service Offices or may be downloaded from the
SSS website (www.sss.gov.ph). The SSS Form L-501 contains the Authorized Signatories of the Household Employer.
(b) In case the Date of Employment of the Kasambahay is earlier than the date of submission of this Form, the basis of the Effective Date of Coverage is the Date of Employment and the
start of the Household Employer's obligation to remit the contributions of the Kasambahay . The Household Employer should proceed to any SSS Branch or Service Office.
7. For Pag-IBIG purposes only:
(a) Household Employer should submit Specimen Signature Form (SSF, HQP-PFF-003) which is available at all Pag-IBIG NCR/Regional Branches or may be downloaded from Pag-IBIG Fund
website at www.pagibigfund.gov.ph.
INSTRUCTIONS
PPS-KUR FORM (V.1)
SOCIAL SECURITY (SS) Number
NAME LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME
(Apelyido) (Pangalan) (Ex. Jr. / II) (Gitnang Pangalan)
DATE OF BIRTH (MMDDYYYY) SEX CIVIL STATUS
MALE FEMALE SINGLE MARRIED WIDOW/ER LEGALLY SEPARATED
PLACE OF BIRTH (CITY, PROVINCE, COUNTRY) RELIGION UMID COMMON REFERENCE NUMBER (IF AVAILABLE)
MOTHER'S MAIDEN NAME LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME
(Pangalan ng Ina noong dalaga) (Apelyido) (Pangalan) (Ex. Jr. / II) (Gitnang Pangalan)
PRESENT ADDRESS UNIT/RM./FLR. NO. BUILDING NAME LOT/BLK./HOUSE NO. STREET NAME
(Kasalukuyang Tirahan) (Bilang ng Yunit at Palapag) (Pangalan ng Gusali) (Bilang ng Lote, Bloke, Bahay) (Kalye)
ZIP CODE
PERMANENT ADDRESS
UNIT/RM./FLR. NO. BUILDING NAME LOT/BLK./HOUSE NO. STREET NAME
(Permanenteng Tirahan) (Bilang ng Yunit at Palapag) (Pangalan ng Gusali) (Bilang ng Lote, Bloke, Bahay) (Kalye)
ZIP CODE
TELEPHONE NUMBER (AREA CODE + TEL. NO.) MOBILE/CELLPHONE NUMBER E-MAIL ADDRESS
SPOUSE LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME DATE OF BIRTH (MMDDYYYY)
(Asawa) (Apelyido) (Pangalan) (Ex. Jr. / II) (Gitnang Pangalan) MALE (Araw ng Kapanganakan)
FEMALE
CHILD/REN LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME DATE OF BIRTH (MMDDYYYY)
(Anak) (Apelyido) (Pangalan) (Ex. Jr. / II) (Gitnang Pangalan) MALE (Araw ng Kapanganakan)
1.
FEMALE
MALE
2.
FEMALE
MALE
3.
FEMALE
MALE
4.
FEMALE
MALE
5.
FEMALE
FATHER LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME DATE OF BIRTH (MMDDYYYY)
(Ama) (Apelyido) (Pangalan) (Ex. Jr. / II) (Gitnang Pangalan) (Araw ng Kapanganakan)
MOTHER LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME DATE OF BIRTH (MMDDYYYY)
(Ina) (Apelyido) (Pangalan) (Ex. Jr. / II) (Gitnang Pangalan) (Araw ng Kapanganakan)
OTHER BENEFICIARY/IES RELATIONSHIP TO REGISTRANT DATE OF BIRTH (MMDDYYYY)
LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME (Araw ng Kapanganakan)
(Apelyido) (Pangalan) (Ex. Jr. / II) (Gitnang Pangalan)
1.
2.

If registrant cannot sign, affix fingerprints to be witnessed by two (2) persons.
Below are the witnesses to fingerprinting:
1)
2)
RECEIVED BY Pag-IBIG PHILHEALTH SSS EVALUATED BY FOR PHILHEALTH USE
(Probinsya/Rehiyon)
PROVINCE/REGION
(Subdibisyon)
Check if NO
Middle Name
Check if NO
Middle Name
PART II - B. DEPENDENT/S OR BENEFICIARY/IES
Check if NO
Middle Name
SEX ( Kasarian )
PART II - C. CERTIFICATION
PART III - TO BE FILLED OUT BY Pag-IBIG/PHILHEALTH/SSS
DATE
PRINTED NAME SIGNATURE
SIGNATURE
DATE
PRINTED NAME
SIGNATURE OVER PRINTED NAME OF REGISTRANT
Republic of the Philippines
KASAMBAHAY
UNIFIED REGISTRATION FORM
(Pursuant to R.A. 10361 or the "Batas Kasambahay")
(Subdibisyon)
PHILHEALTH Identification Number (PIN)
(Kasarian)
CHECK IF NO MIDDLE NAME
(I-tsek ang kahon kung walang
gitnang pangalan)
(Barangay/Distrito)
(Relihiyon)
PART I - PLEASE INDICATE YOUR MEMBERSHIP NUMBER IF ALREADY REGISTERED
(Paki lagay ang inyong numero sa Pag-IBIG, PhilHealth or SSS kung myembro na)
Pag-IBIG MID Number/RTN
THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE
SIGNATURE OVER PRINTED NAME DATE & TIME
(Ako ay nagpapatunay na ang aking mga isinaad sa itaas ay totoo at tama na nararapat para ako ay ma-rehistro bilang miyembro ng Pag-IBIG, PhilHealth at SSS.)
DATE & TIME BRANCH SIGNATURE OVER PRINTED NAME
DATE
BARANGAY/DISTRICT
(Use another sheet if necessary)
I hereby certify that the information supplied above are true and correct for the purpose of my registration in the three (3) social security agencies
of the Philippine Government, namely, Pag-IBIG, PhilHealth & SSS.
Check if NO
Middle Name
CHECK IF NO MIDDLE NAME
(I-tsek ang kahon kung walang
gitnang pangalan)
PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK OR
.BLUE INK ONLY. (Basahin ang mga Instructions sa likod ng Form bago ito sulatan. Isulat ang lahat ng impormasyon sa MALALAKING TITIK at gumamit lamang ng . ITIM o
ASUL na tinta.)
(Araw ng Kapanganakan)
PART II - A. PERSONAL INFORMATION
SUBDIVISION BARANGAY/DISTRICT
(Probinsya/Rehiyon)
(Sibil na Katayuan)
PROVINCE/REGION
MUNICIPALITY/CITY
(Lugar ng Kapanganakan)
SUBDIVISION MUNICIPALITY/CITY
CHECK IF W/
PERMANENT
DISABILITY
Check if NO
Middle Name
CHECK IF W/
PERMANENT
DISABILITY
(Munisipyo/Syudad)
CHECK IF W/
DISABILITY
(Barangay/Distrito) (Munisipyo/Syudad)
RIGHT THUMB
RIGHT INDEX
!" 8eglsLer Lo any of Lhe Agencles (agl8lC/hllPealLh/SSS).
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* noL yeL needed aL Lhe Llme of reglsLraLlon for Lhe lssuance of agl8lC/hllPealLh/SSS numbers.
* lf noL avallable aL Lhe Llme of reglsLraLlon, reglsLranL wlll sLlll be provlded Lhe correspondlng numbers. Powever, avallmenLs of any beneflLs shall only
be allowed upon submlsslon of documenLs Lo prove hls/her ldenLlLy and paymenL of requlred premlum conLrlbuLlons.
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SubmlL phoLocopy & presenL orlglnal/cerLlfled Lrue copy of any of Lhe ff:
* 8lrLh CerLlflcaLe
* 8apLlsmal CerLlflcaLe
* urlvers Llcense
* assporL
* rofesslonal 8egulaLlon Commlsslon (8C) Card
* Seaman's 8ook
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ln Lhe absence of rlmary uocumenLs, submlL phoLo copy and presenL orlglnal/cerLlfled Lrue copy of 1WC (2) of Lhe followlng, 8C1P should
bear Lhe name and aL leasL CnL (1) should lndlcaLe Lhe uaLe of 8lrLh:
* A1M Card
* 8ank AccounL assbook
* 8lrLh/8apLlsmal CerLlflcaLe of Chlldren
* Marrlage ConLracL
* n8l Clearance
* ollce Clearance
* osLal lu Card
* voLer's lu/AffldavlL
* School 8ecords
* lu Card lssued by Local CovernmenL unlLs (e.g. 8arangay, Munlclpal/ClLy)
lf Lhe requlred supporLlng documenL/s ls/are noL avallable aL Lhe Llme of reglsLraLlon, or lf reglsLraLlon ls done aL agl8lC/hllPealLh, or lf Lhe
8eglsLranL ls unavallable Lo slgn Lhe documenL, SS number shall sLlll be lssued, sub[ecL Lo Lhe followlng condlLlons:
* Membershlp SLaLus of kasambahay ls "1emporary".
* 1he SS number lssued can only be used for conLrlbuLlon paymenL and
employee reporLlng (by Lhe Pousehold Lmployer).
* Submlsslon of rlmary or Secondary documenL/s and/or slgnaLure ln Lhe
lorm ls requlred for converslon of Membershlp SLaLus Lo ermanenL,
Lhru Member's uaLa AmendmenL lorm (SSS lorm L4)
* AvallmenL of SSS 8eneflLs and Loans ls only allowed for ermanenL
Membershlp SLaLus, sub[ecL Lo quallfylng condlLlons.
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