Government Service Insurance System Financial Center, Pasay City, Metro Manila 1308 OFFICE ORDER NO. 345-19 SUBJECT: Revised Documentary Requirements for Social Insurance Benefits and Other Related Claims and Transactions The following are the revised documentary requirements for Social Insurance benefits and other related claims and transactions. The list of acceptable government-issued identification cards and other pertinent application forms for each claim are herein Provided for implementation of the operating units. A. RETIREMENT/ SEPARATION BENEFIT 1. Compulsory! Optional Retirement (RA 8291, RA 660, PD1146, RA 1616)/ Separation Benefit (RA 8291) ) Duly accomplished Application Form for Retirement/ Separation Life Insurance Benefits b) Service Record with Leave Without Pay (LWOP) Certification (indi specific dates and time of LWOP) ©) Declaration of Pendency/ Non-Pendency of Case (DPNPC) Form (date administered/ notarized should be on or after receipt of notification from GIS) ting the 2, Disability Retirement (RA 8291) a) Duly accomplished Application Form for Disability Benefit b) Proofs of Disability Parts |, Il, and Ill ©) Service Record with Certification indicating the specific dates and time of sick leave with and without pay 4) DPNPC Form (date administered/ notarized should be on or after receipt of Notification from GSIS) 3. Portability (RA 7699) a) Duly accomplished Application Form for Retirement Benefit under RA 7699 ») Certification of SSS premium contributions indicating number and inclusive ‘months of contributions signed by authorized SSS Officer ©) Service Record with LWOP Certification (indicating the specific dates and time of LWOP) 4) DPNPC Form (date administered/ notarized should be on or after receipt of notification from GSIS) B. LIFE CLAIM 1, Maturity or Gash Surrender Value (Regular! Optional) 8) Duly accomplished Application Form for Retiremen¥/ Separation Life Insurance Benefitsb) Service Record with LWOP Certification (indicating the specific dates and time of LWOP) 2, Death Claim! Accidental Death Benefit - Life Endowment Policy (LEP) a) Duly accomplished Application Form for Retirement! Separation/ Life Insurance Benefits b) Service Record with LWOP Certification (indicating the specific dates and time of LWOP) ©) Death Certificate of member issued by Local Civil Registrar (LCR) or Philips Statistics Authority (PSA) (formerly National Statistics Office or NSO); or authenticated by Philippine Consular Office, if died abroad 4) Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form, if with minor incapacitated children (for cases with no designated beneficiaries only) ) Court Order, or Affidavit of Surviving Legal Heirs/ Surviving Spouse Guardianship Form supported by a Report or Certification issued by the DSWD Office where the minor/ incapacitated dependent child is residing, if the guardian is not the natural parent 1) Birth Certificate/s Issued by LCR or PSA or valid passport or two (2) valid government-issued IDs with date of birth and signature, if designated beneficiaryfies /payee/s is/are not GSIS member 9) Marriage Contract of female beneficiarylies issued by LCR or PSA h) Police Investigation Report, if death is due to accident 3. Death Claim (ELP Policy) a) Duly accomplished Application Form for Retirement’ Separation’ Life Insurance Benefits b) Service Record with LWOP Certification (indicating the specific dates and time of LWOP) ©) Death Certificate of member issued by LCR or PSA; or authenticated by Philippine Consular Office, if died abroad ¢) Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form, if with minor/ incapacitated children ©) Court Order, or Affidavit of Surviving Legal Heirs/ Surviving Spouse! Guardianship Form supported by a Report or Certification issued by the DSWD Office where the minor/ incapacitated dependent child is residing, if the guardian is not the natural parent f) Birth Certificate/s issued by LCR or PSA or valid passport or two (2) valid government-issued IDs with date of birth and signature, if designated beneficiaryfies /payee/s is/are not GSIS member 9) Marriage Contract of female beneficiary/ies issued by LCR or PSA C. FUNERAL BENEFIT 1. Claimant Is the spouse a) Duly accomplished Application Form for Funeral Benefit b) Death Certificate of member issued by LCR or PSA; or authenticated by Philippine Consular Office, if died abroad 2©) Marriage Contract of member with the surviving spouse issued by LCR or PSA 4) Birth Certificate issued by LCR or PSA or valid passport or two (2) valid government-issued IDs with date of birth and signature, if surviving spouse is not a GSIS member 2. Claimant Is Other than the Spouse a) Duly accomplished Application Form for Funeral Benefit b) Death Certificate of member issued by LCR or PSA; or authenticated by Philippine Consular Office, if died abroad ©) Birth Certificate issued by PSA or two (2) valid governmentissued IDs with date of birth and signature, if claimant is not a GSIS member 4) Death Certificate of legal spouse issued by LCR or PSA, if married €) Notarized waiver in favor of the claimant with two (2) valid governmentissued IDs of the legal spouse with signature, if legal spouse is living ) Affidavit of the claimant stating that despite earnest efforts, the legal spouse cannot be located to sign a notarized waiver in favor of the claimant attested by two (2) disinterested persons and their two (2) valid government-issued IDs, if the legal spouse cannot be located 9) Official receipt of funeral expenses issued in the name of the claimant D, SURVIVORSHIP BENEFIT 1. Member! Pensioner with Primary Beneficiary/ies a) Married i, ii, wv. ve vi vil, b) Single i, Duly accomplished Application Form for Survivorship Benefit Death Certificate of member issued by PSA; or authenticated by Philippine Consular Office, if died abroad Marriage Contract of deceased member issued by LCR or PSA Affidavit of Surviving Legal Helrs/ Surviving Spouse/ Guardianship Form Birth Certificate/s of minor/ incapacitated children issued by LCR or PSA Birth Certificate issued by LCR or PSA, or valid passport, or two (2) valid government-issued IDs with date of birth and signature, if spouse is not a GSIs member Court Order, or Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form supported by a Report or Certification issued by the DSWD Office where the minor/ incapacitated dependent child is residing, if the guardian is not the natural parent Duly accomplished Application Form for Survivorship Benefit Death Certificate of member Issued by PSA; or authenticated by Philippine Consular Office, if died abroad Birth Certificate/s of minor/ incapacitated children issued by LCR or PSA Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form Affidavit of Surviving Legal Heirs/ Surviving Spouse! Guardianship Form supported by a Report or Certification issued by the DSWD Office where the minor/ incapacitated dependent child is residing or Court Order, if the guardian is not the natural parentvi, Birth Certificate issued by LCR or PSA, or valid passport or two (2) government-issued valid IDs with date of birth and signature, if guardian is not a GSIS member 2. Member Is single without primary beneficlary and survived by parents only a) Duly accomplished Application Form for Survivorship Benefit b) Death Certificate of member issued by LCR or PSA; or authenticated by Philippine Consular Office, if died abroad ©) Birth Certificate of member issued by LCR or PSA 4) Birth Certificate of member's surviving parents issued by LCR or PSA or valid Passport or two (2) valid government-issued IDs with date of birth and signature 3, Member Is Single without primary beneficiary and survived by siblings only a) Duly accomplished Application Form for Survivorship Benefit b) Death Certificate of member issued by LCR or PSA; or authenticated by Philippine Consular Office, if died abroad ©) Birth Certificate of member issued by LCR or PSA @) Death Certificate of member's parents Issued by LCR or PSA ) Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form ) Birth Certificate of member's surviving heirs (siblings) issued by LCR or PSA or valid passport or two (2) valid government-issued IDs with date of birth and signature 4. Release of Pension Credited to E-card Account after Death a) Member's Request Form (MRF) . PRE-NEED CLAIMS 4. Edu-chitd ‘@) Availment of College Education Benefit (CEB) i. For initial avaiiment a. Duly accomplished Application Form for Pre-Need Plans b. Course Curriculum indicating the number of units and subjects to be taken by the scholar ¢. Certificate of Full Payment (CFP), if issued to the planholder 4. Official Receipt of the tuition and other standard school fees. e. Registration Form with Assessment/ Schedule of Fees ji, For Succeeding Availments a. Duly accomplished Application Form for Pre-Need Plans . Registration Form with Assessment! Schedule of Fees ¢. Official Receipt of the tuition and other standard school fees b) Un-availed College Educational Benefit |. Duly accomplished Application Form for Pre-Need Plans li. Certificate of Full Payment (CFP), if issued to the planholder¢) Unused Units/Retirement Benefit (10 years after graduation) i. Duly accomplished Application Form for Pre-Need Plans i, Transcript of Records 2. Memorial Pian a) Enhanced Optional Exit Mechanism (EOEM) i, Duly accomplished Application Form for Pre-Need Plans i, Certificate of Full Payment (CFP), if issued to the planholder b) Death Claim i. Duly accomplished Application Form for Pre-Need Plans ji, Death Certificate of planholder issued by LCR or PSA; or authenticated ilippine Consular Office, if died abroad of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form v. Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form supported by a Report or Certification from DSWD office where the minor/ incapacitated dependent child is residing, or Court Order, if the guardian is not the natural parent V. Certificate of Full Payment (CFP), if issued to the planholder 3. College Education Assurance Plan (CEAP) a) Duly accomplished Application Form for Pre-Need Plans 4, Family Hospitalization Plus Plan (No Availment Bonus) ) Duly accomplished Application Form for Pre-Need Plans F. EMPLOYEES COMPENSATION 1. Sickness a) Duly accomplished Form for Income Benefit Claim for Payment, Part | and II b) Duly accomplished Form for Hospitalization Claim for Payment, Parts I, Il, and nt ¢) Hospital/ Clinical records of confinement/ consultation due to claimed ailment 9) Service Record with Certification indicating the specific dates and time of sick leave with and without pay 2. Injury (Non-battle) a) Duly accomplished Form for Income Benefit Claim for Payment, Part | and It b) Duly accomplished Form for Hospitalization Claim for Payment, Parts |, Il, and i ¢) Hospital/ Clinical records of confinement/ consultation due to claimed ailment @) Service Record with Certification indicating the specific dates and time of sick leave with and without pay ©) Certification under oath by Head of Office narrating in detail the circumstances Surrounding the accident (e.g. time, date, place of accident, what employee ‘was doing at the time of accident and reason or purpose of being there) 1) Affidavit of witnesses to the accident9) Travel Mission Order/ Personnel Pass, if injury! accident happened outside office premises h) Police Accident/ Investigation Report, if applicable (e.g. vehicular accident, shooting incident, stabbing incident, etc.) i) Line of Duty Board Proceedings for AFP members 3. Wounded In Action (WIA) a) Duly accomplished Form for Income Benefit Claim for Payment, Part | and II b) Duly accomplished Form for Hospitalization Claim for Payment, Parts |, II, and im ¢) Hospital/ Clinical records of confinement /consultation due to claimed ailment 4) Service Record with Certification indicating the specific dates and time of sick leave with and without pay ©) Certification under oath by Head of Office narrating in detail the circumstances Surrounding the accident (e.g. time, date, place of accident, what employee was doing at the time of accident and reason or purpose of being there) 1) Authenticated copy of Operations Center Journal Entry 9) Original or Authenticated copy of Spot Report h) Original or Authenticated copy of Progress Report 4. Death Claim (Non-battle) - see requirements a— 1 for Injury (Non Battle) a) With primary beneficiaryries |. Death Certificate of member issued by LCR or PSA Marriage Contract of member issued by LCR or PSA Birth Certificate of legitimate minor/ incapacitated children, 21 years old and below issued by LCR or PSA iv, Birth Certificate issued by LCR or PSA or valid passport or two (2) valid government-issued IDs with date of birth and signature, if spouse Is not a GSIS member! pensioner v. Affidavit of Surviving Legal Heirs? Surviving Spouse/ Guardianship Form vi. Court Order or Affidavit of Surviving Legal Heirs/ Surviving Spouse Guardianship Form supported by a Report or Certification from DSWD office where the minor! incapacitated dependent child is residing, if the guardian is not the natural parent b) Secondary beneficiaries (parents and illegitimate children) - s requirements a~ I for Injury (Non Battle) |, Death Certificate of member issued by LCR or PSA li, Birth Certificate of member issued by LCR or PSA tii, Birth Certificate issued by LCR or PSA or valid passport or two (2) valid ‘government issued IDs with date of birth and signature, if parents are not GSIS member/ pensioner \v. Birth Certificate of illegitimate children 21 years old and below issued by LCR or PSA V. Affidavit of parents that member died single with or without illegitimate children and that they are wholly dependent upon the deceased for support Death Certificate of parents, if deceased legal5. vii. Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form for minor dependent child, if with minor/ incapacitated children vil. Court Order or Affidavit of Surviving Legal Heirs! Surviving Spouse/ Guardianship Form supported by a Report or Certification from DSWD. office where the minor/ incapacitated dependent child is residing, if the guardian is not the natural parent Killed In Action (KIA) with primary beneficiaries a) Duly accomplished Form for Income Benefit Claim for Payment, Parts | and Il 'b) Service Record with Certification in cating the specific dates and time of sick leave with and without pay ©) Certification under oath from the Head of Office/ Commanding Officer narrating in detail the circumstances surrounding the accident (e.g. time, date, place of accident, what employee was doing at the time of accident and reason or purpose of being there) d) Authenticated copy of Operations Center Journal Entry ) Original or Authenticated copy of Spot Report ) Original or Authenticated copy of Progress Report 9) Original or authenticated copy of Casually Report h) Death Certificate of member issued by LCR or PSA i) Marriage Contract of member issued by LCR or PSA J) Birth Certificate of legitimate minor/ incapacitated children, 21 years old and below issued by LCR or PSA. ‘k) Birth Certificate issued by LCR or PSA or valid Passport or two (2) valid government-issued IDs with date of birth and signature, if: ‘spouse is nota GSIS- member/ pensioner |) Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form m) Court Order or Affidavit of ‘Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form supported by a Report or Certification from DSWD office where the minor/ incapacitated dependent child is residing, if the guardian is not the natural parent Killed In Action (KIA) with secondary beneficiaries (parents and illegitimate children) - see requirements a~e, h for Killed In Action (KIA) with primary beneficiaries a) Birth Certificate of member issued by LCR or PSA b) Birth Certificate issued by LCR or PSA or valid passport or two (2) valid government issued IDs with date of birth and signature, if parents are not GSIS member! pensioner ©) Birth Certificate of illegitimate children 21 years old and below issued by LCR orPSA 4) Affidavit of parents that member died single with or without illegitimate children and that they are wholly dependent upon the deceased for support ©) Death Certificate of parents, if deceased 1) Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form for minor dependent child, if with minor/ incapacitated children9) Court Order or Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form supported by a Report or Certification from DSWD office Where the minor! incapacitated dependent child is residing, if the guardian is not the natural parent 7. Death of a PTD Pensioner (Transfer of Pension) a) Duly accomplished Application Form for Income Benefit Claim for Payment, Part | only b) Death Certificate of member-pensioner issued by LCR or PSA or authenticated by Philippine Consular Office, if died abroad f qualified for transfer of pension, the following additional documents shall be required: a) Marriage Contract of deceased pensioner issued by LCR or PSA b) Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form ¢) Birth Certificate issued by LCR or PSA or valid passport, or two (2) valid government-issued IDs with date of birth and signature, if spouse is not a GSIS member @) Birth Certificate’s of minor! incapacitated children issued by LCR or PSA e) Court Order or Affidavit of Surviving Legal Heirs/ Surviving Spouse! Guardianship Form supported by a Report or Certification from DSWD office Where the minor! incapacitated dependent child is residing, if the guardian is not the natural parent G. OVER THE COUNTER (OTC) LOANS GRANTING 4. Ifwith eCard/ UMID/ Temporary Card a) Duly accomplished Application Form Note: eCard/ UMID/ Temporary Card should be presented 2. If lost/ defective! damaged eCard ‘a) Duly accomplished Application Form b) Affidavit of loss ©) Official Receipt issued by the servicing bank for replacement, if UMID card 4) Valid passport or two (2) valid government-issued IDs H. REQUEST FOR CHECK REPLACEMENT 1. Check Released to Payee a) Lost Check Alteration and Replacement Form (CARF) Affidavit of Loss b) Damaged i. CARF Physical Checkfii, _ UMID or eCard or valid passport or two (2) valid government-issued IDs with date of birth and signature ©) Deceased Payee i. CARF Physical check Death Certificate issued by LCR or NSO; or authenticated by Philippine Consular Office if died abroad, if no claim for funeral benefit has been filed lv. Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form, if no claim for survivorship benefit has been filed Birth Certificate issued by LCR or PSA or valid passport or two (2) valid government-issued IDs with date of birth and signature, if payee is not a GSIS member vi. Extra judictal settlement among the legal heirs of the deceased d) Wrong Payee Name i. CARF i, Physical Check i. Birth Certificate of the Payee issued by LCR or NSO W,__UMID or eCARD or valid passport or two (2) valid government-issued IDs €) Stale check i. CARF ii, Physical Check 2. Check with GSIS. a) Lost L CARF li, Notarized Incident Report prepared by the concerned personnel with the custody of the check, duly noted by the DC, Officer ! or Extension Head, whichever is applicable b) Deceased Payee i CARF Death Certificate issued by LCR or NSO; or authenticated by Philippine Consular Office if died abroad, if no claim for funeral benefit has been filed lil, Affidavit of Surviving Legal Heirs/ Surviving Spouse/ Guardianship Form, if no claim for survivorship benefit has been filed iv, Birth Certificate issued by LCR or PSA or valid passport or two (2) valid government-issued IDs with date of birth and signature, if payee is not a GSIS member v. _ Extra judicial settlement among the legal heirs of the deceased ©) Wrong Payee Name iL CARF li, Birth Certificate of the Payee issued by LCR or NSO iii, __UMID or ECARD or valid passport or two (2) valid government-issued IDs. d) Stale Check i CARFCHECK RELEASING 1. To Payee a) Duly accomplished Check Delivery Receipt Form (CDRF) b) E-card/ UMID card/ valid passport or two (2) valid government-issued IDs and photocopies of the same 2. To Authorized Representative a) Duly accomplished CDRF ») Written Authorization signed by the payee or duly notarized Power of Attorney, if payee Is residing in the Philippines ©) Special Power of Altorney (SPA) duly notarized in the Philippine Embassy where the payee Is residing, if the payee is living abroad ) E-card or UMID card or valid passport or two (2) valid governmentissued IDs of the payee and representative and photocopies of the same, if residing in the Philippines e) E-card/ UMID card/ valid passport or two (2) valid government-issued IDs of the representative and photocopies of the same, if living abroad 3. To Liaison Officer a) Duly accomplished CDRF b) Liaison Officer's ID UST OF ACCEPTABLE GOVERNMENT-ISSUED IDENTIFICATION CARDS (IDs)/ DOCUMENTS |. e-Card/ UMID Employee's ID/ Office ID Driver's License * Professional Regulation Commission (PRC) ID * Passport * Senior Citizens 1D sss ID COMELECY Voters ID/ COMELEC Registration Form 8. NBI Clearance * 10. Integrated Bar of the Philippines (IBP) ID 11. Firearms License * 12. AFPSLAI ID * 13.PVAO ID 14.AFP Beneficiary ID 15.BIR (TIN) 16. Pag-ibig ID 17.Persons With Disability (PWD) ID 18.Solo Parent ID 19, Pantawid Pamilya Pilipino Program (4Ps) ID * 20. Barangay ID * 21. Philippine Postal ID * PNOMAYNS 1022.Phikhealth ID 23.School ID ** 24. Other valid government-issued IDs/ Documents with picture and signature * within its validity period “private/ government schoo! K. OTHER PERTINENT RULES 1. Additional documents may be required for purposes of further validation and Verification (e.g., adverse claim, name, appellation, date of birth, presumption of death, ete.); For disability and Employee Compensation benefits, other documents may be required by the Medical/ Legal Evaluator; Original copies of documents should be presented by the member/ claimant; If member dies while claim is being Processed, additional requirements shall be required; In case member is unable to sign, affix thumb mark and two (2) witnesses are required to sign in the form and present e-Card/ UMID or valid passport or two (2) valid government-issued IDs and their Photocopies 6. The written authorization or Special Power of Altorney (SPA) should ensure that the following are present: * Date the instrument was executed ‘Names and complete addresses of the principal and the agent ‘Specific transaction the principal authorizes the agent to do in his/her behalf Signature of the principal Acceptance of the Agent or. ‘Attorney-in-fact Acknowledgement, if SPA 7. Extra Judicial Settlement among the legal heirs of the deceased brother/ sister of the member designating one payee (if net proceeds is more than P100,000.00, Publication of the same is required) 8. All pertinent documents such as Certificates of Birth, Marriage and Death issued abroad must bo authenticated by the Philippine Consular Office. 2 aw np The list of codified forms and attachments are shown in Annex “A*, All Office Orders, Circulars, Policy and Procedural Guidelines inconsistent herewith are hereby superseded, modified or repealed accordingly. This Office Order shall take effect immediately. Az. NORA MALUBAY-SALUDARES pacer Chae, Office of the President and General Manager Date Signed: 24 20, uFerm to APPLICATION FOR RETIREMENT/SEPARATION/LIFE INSURANCE BENEFITS (Pease read Terms and Conditions and Documentary Requirements atthe back) TWSTRUCTIONS: Ensure that the applcaion Tors propery filed out and submit du accomplahed appation Form to Whe nearest GSI Office. WARNING: rect or Indrect commission of fraud, cofusion, falsNeation, mirepretentation of facts, or any other kind of snomly inthe accomplishment ofthis form, orn taining any benef under this applcationshallbe subject to administrative, ed ander erminsl ation, bate: ' hereby apply for areticement/separation/ife Insurance benefit with the GSIS and declare to the best of my knowledge the followit ‘at tiame Fat heme Tidaie ame (Sis Business Paine (BF), Complete Watling Adaress Dake ot BA Tama Fine oF Bh Gender 1 Ferate [2] wate Conta Wo (aineT Tephane We Tmaeatres casa inane, tame of Spouie: (ast Name, Fr Nae, CKomeries since Meare) D7 separatea C1 wisowrwidower Date of Marriage: Tiree Separaion Bani Prev Avaed (APPT) Lrassco eases CJ rons C] mes: thave the honor to apply for [Retirement beneits under the rerement node marked Below, efecve Tati ‘my signature beside my chosen option (Please refer tothe Terms and Condons ofeach retirement mode on subsequent pages) RETIREMENT LAW. RETIREMENT OPTIONS SIGNATURE A660 | LT Below age 60, manthly annuity payable annua Tor yeors [El aeedcotobctw 2 Syear ture sum,2yearsbatnce pate on {hea eranday monty anny afer te yor gunarend pod sees63 end above, searlup sum maths ae Yat Giarnted period a IE] somone xeasc ont Penson (oP and BP ater yes a {El option 2:38 mont x BMP and BP co starton dato etrement TATEIS | Ey Round af erent Prefosebrement aay abe paid bya Erplyer TFET FOR |TV OF EW BRETT TE WH OTT CURTE BOTY PE You a TET ‘ase | costondng lon abigovonon stint Sts nce the Coe of tan amoroton sted fr Pensioners (CLASP program. The remalning balance of your oustanding obligation shal be estvctuted 25 a loon with an Interest rate of 10% per ennum compounded onnuoly (paca). Please Indicate your ‘choices below! [As payment for my outstanding bgation, please deduct from the proceeds of my retirement benefit the amount equivalent to: 100% since lam not avling the CLASP 75%, remaining balance of 258 shell be paid trough CLASP 50%, remalning baance of 50% shall be pad through CLASP 25%, remaining balance of 75% shall be pad through CLASP Preferred repayment term forthe remaining balance: [I] 1year [] 2years (Cl 3vears SEPARATION GENEFTT (PD 1346/RA 8291) effective (mma ‘SiGHATURE (a cilia a ere Tahar 1S yoo see Ca Boel Gane ae ET xen [I eiow sens la win shan 25 rn serie (ah Soe yale se 6) Below 60 years old with more than 15 years In serdce (Cash Deneft payable wpon separation and monthly penson upon reaching age 60)‘TERMS AND CONDITIONS. RETIREMENT. AL ELGIBILTY REQUIREMENTS 44. Member shall be entitled to the retirement benef, provided Members separated from the service atthe time of applieation, and on contin th UUnderRA6s0 | 3. Member hasbeen the service on or before May 33,1977; 2 Member must be on permanent status at the time of relcement with continuous sere for the lst three (3) prior to retirement and has made cntebutions for atleast five () years; and 3, Member has met the age and service requirement (YOS) as ndleated below: ‘age [2 [$3 [54155 [56] 57 [sa [50 [oo [ou [ea [os [oa [os vos {as /ae{33 {sz} 3i{ s0 [zs [2s [24] 22 | 20 [38 [36 [35 ‘Member should have been separated/retied on or before tune 23, 1997; and Member has rendered atleast ifteen (15) years of service Inthe government. ‘Under PO 146 Fi 2 ‘UnderRas201 [3. Member should have been separated/tetired on or after lune 28, 19975, 2. Member has rendered at least ten (15) years of service Inthe government, 3. Memberis atleast sity (6) year of age atthe time of retirement 4‘ Member Is not receiving a monthly pension beneft due to permanent total isbity; end '5.__Member must not bea uniformed personnel of PNP, IMP and BF. x 2 ‘UndermA 1616 | 3. Member has been Inthe service on or before May 33,1977; ‘Member, regardless of age, must have atleast twenty (20) years of service nthe government atthe time of rticements and 3. Member must have rendered continous service forthe fst three (2 years and must not ‘cur leave without pay of more than one (1) year except in care of death, sabi, ‘bolitln or phase-out of postion due to reorganeaton. Except for teachers who are allowed more than one (1) year leave without pay under the Magna Carta for Teachers. 2. Request for conversion from one mode of reirement to another shal not be alowed. ‘3. The retirement proceeds shall at all times be subject to deduction for any outstanding indebtedness the member ‘may have incurred with GSI, pursuant to Arties 1231 and 1278 ofthe Chl Code, GSI Laws (RA 6E0, PD 1146, RA, 1616, RA 8291 and PO 1146) and existing polices. CONDITIONS FOR RECEIPT OF MONTHLY PENSION ‘Upon reaching the age 60, or after the end of the 5-year guaranteed period, the qualified pensioners requiced to esonaly appear at 1s Oe newest hi/ner place of reldence. Mamba shallbereqle to request for fommencement of person and afterwards era forthe GIs UMID-ComplonteCord/Mork arsction cord Previously retreat age tnd snvvorthp pensioners shal longer be egied to oehy ain ine Aa Aenewal of Atv statu (MBAS) EXCEPT: 4) Pensoners on suspended status ee Api 0, 7011 and hos not renewed Active status af present dates and 2) Penones whose ih month alsin 204 on te mona Feuer arch or Ar The pensioners ving abrod orn the At Reon sal be eget comply the AAS on ther bith month every yea SEPARATION [A ENTTTIEMENT TO SEPARATION BENEFITS UNDER RA #291 AAmember who has azurlated minimum of tre) yeas rectal service sl be ented tsepratonbenet Upon rerigration or seperation under the folowing rma 1. Formember with st least three (3) years but less than fifteen (15): ‘cash payment eqhalent to one hundred percent (100%) ofthe average mnthy compensation for every yar of “real seres the momber has pad contin, battles hon Tele Tsuna Pees (P1600), Bvable upon reaching sity yeus foe or upon separation whicaver comes oer 2. Formember witht lat iteen 15] years of src nd les than sty (2) years of ge upon separation: Aesth payment equbalettalehteen (18) tines the bse monthly pense, peyabe atthe time of resgnaon or separa ' Anokdage pension benefit equal tothe basi monthly pension payable month fr fe pon reaching ge. 8 PRESCRIPTIVE PERIOD FOR FLING OF SEPARATION BENERT ‘Applleation for separation benefits must be Med within four (2) years from the date of separation at provided for under RAg201. ‘COMPULSORY LIFE INSURANCE BENEFITS UNDER THE LIFE ENDOWMENT POLICY (LEP) _Amember under this policy may be entitled to any ofthe following benefts, depending onthe circumstances: T_ Maturity benefit “he face amount payable to the mernber upon maturity ofthe pole. "2. Cash Surrender Value | The earned values during the term of the insurance payable to the member when Rel separated trom the service before maturity date ofthe policy or when he Is considered asa case of Permanent Total Disablity (PTD), 3 beaih Benet ‘Te face value ofthe pole payable to designated benefidary/beneTcivies or Tegal his, inthe absence ofthe former, upon the death ofthe member, TeenialDeah Benet An adina ene equalent to We amount ef Death Senet when the ember GatIL 6a years ord and above with as than 15 year Tn sence (Cash Benet payable Immediate) ‘Declaration of | lundertate to submit my Declaration of Pendeney/on Pendency of cae, uly subveribed and sworn To Pendency/Hon- | before a Notary Public or Administering Ofeer of my agency-employer, as a condition forthe release of Pendency of Case | my retirement benefit and in cmpllance with Section of CSC Resolution No, 1202242 dated 1 October 2013, [Ey ure sunawce sewertr Type aflife insurance: [-] Compulsory [1] Optional | Paley No. (if clairing Yor Optional Pai) NAME OF CLAIMANT IF MEMBER IS DECEASED: ‘ast fame FirstName Wide Kame ‘Gis Business Parner (BP) NO. Complete Maing Address Date of Ah (/ETTIN Tolan to Deceased Merber ‘Contact fa ealphone No. 6 of benefit applied for ‘Maturity Benefits 5) cash surrender Value/Termination Valu, in view of my retirement effective [Gy resignaton/separation from the government senice on Ey sate otnerreason/s IZ] vesth Benefits: Date of Death: 51 Accisental Death Benefit (x02) (applicable Yor CMILEP)/Optional polices) Rts understood that the entre outstanding balance of my polcy as wells the arrearages and balances of my other loans ‘and accountabilities with the SIS which are due and demandable shall be deducted from the sid benefit pursuant to Articles 4251 and 1278 ofthe Cl Code ofthe Philppines, RA 8291 and the exlstig poleles of the GSI. Printed Name and signature of Witnesses to Thumb marke ‘aim proceeds sha be electronically erelted to your eCard/UMID count and maybe withdrawn from your nearest bank or ATM, Ifyou hve no eCord/UMIO, the proceeds wil be pold through check ‘TO BE FILLED OUT BY HEAD OF AGENCY OR HIS AUTHORIZED ENDORSING OFFICER —] tndorsement ‘especttliy forwarded to GBs his application for retrement/sopaation/ie insurance Benelt with our Fecommendation for approval. itis hereby certified thatthe applicant: (lace a chock (} mark on the pertinent boxeny) 1. D) has no pending administrative/criminal case. 2 Ef rascenin intitle 5. Ey hasa decided administrative cate with (Picasa Hach cried copy of Decaion) ‘4. Ei] asa decided exinal care with (Pease attach certified copy of Decislon) 5. Isappiing for Refund of Premns under RA 1616 andthe application fr gratlty benefit has Been approved bythis Office “Gignature over printed name ofthe Head eTAgency Date SIGNED: lorhis Authorted Endorsing Ofer office Name Office Address ‘Application Recelved By: Date Received: ‘TMS Reference No:‘he ease ofthe members deaths accidental, The Hight present sufient proof to show that death wa aceldental shall presribe thecal fr ADB I fed four (8) years after the death ofthe member. 5 Ganphadend ‘A poleyholder I ented to dlvidends subject to the gudeIne Board. This isnot aguaraned benef, ‘approved by the GSS ‘COMPULSORY LIFE INSURANCE BENEFITS UNDER THE ENHANCED LIFE POLICY (E1P) ‘Amember under this policy may be ented to any ofthe following benefits, depending onthe circumstance Death penetie "Equivalent tothe latest annalsatary mulipied bythe amount of Insurance (AO) Gar Which s 15 oF 38 times the current monthly salary ofthe member or as determined by the GSI, payable to the legal helrs, less all oustanding oblgtions of the member In accordance with Articles 1231 and 1278 of the Cv Code, GSIS Laws (RA 6E0, PD 1146, A616, RA 8291 and PD 1146) and esting poleles. 2 Tenrination Vatoa OV) ‘The poleyearns.a TV during the eof the polcy computed from te percentage fhe Me insurance premlums actualy remitted and pald to CSIs, TVis equivalent to Percentage of monthly Ife insurance premiums as determined bythe GSS, due and ald full ether by dectremitance or through an APL fait, The accumulated TV ‘il grow at such rate as determined by the Actuary and shall be pad to the member ‘upon his separation fom the government servic lesa Indebtedness ofthe member ith the GSS in accordsnce with ticles 1281 and 1278 ofthe Civ Code, GSS Laws, {(RA.6E0, PD 1145, RA 1616, BA291 and PO 1346) and existing poles, 3 Gain biddend ‘A policyholder i enttied to dividends subject to the guidelines as approved bythe GBS Board. This Is not a guaranteed benef, ‘OPTIONAL LIFE INSURANCE POL ‘Amember under this policy may icv (OUP) be entitled to any ofthe folowing benefits, depending onthe ckcumstances: T Maturity Benefit “The face amount payable tothe member upon maturity ofthe policy less ndeDTeaney ‘consisting of premium arrearages and polly loan balance. 2 Gaih Surender valve ‘The palcy reserve earned bythe polcy atthe end ofeach anniversary year, Alter HE Insurance have been in fore for one J) year, It begins to earn cash valve wich Increases annually, but whlch never exceeds the face vale ofthe polly. The CSV of the potcyes Indebtedness and surrender charges the amount which the GIS wil pay to any polyholder in the event Member surrenders the poly. 3 Diabiity Benet ‘Adlsabity claim arises when during the paying period that the pole sla free; he Boleyholder becomes permanently and totaly csabed before his 6O™ birthday, ‘whether the csaity is eaused by Iiness or injury, Upon permanent and total. lsabity, premium payments onthe policy wll not be required from the approved date of ably Death Benefit “The face value of the pole payable Yo edignated beneficiary /beneTines oT thts Inthe absence ofthe former, upon the death ofthe ember. ‘ecidental Death Benett ‘An additonal beneftequlvafent tothe amount of Oeath Benefit when death occured ‘within ninety (90) days from the date ofthe acldent. In this connection, proof must be presented to sufficiently establsh that the cause ofthe member's deaths aecidental. & cash Owidend ‘8 poleyholder i ented to dvdends subject to the guidelines as approved bythe GS Board. Tis snot a guaranteed benef fomass) We laurare Benefit DOCUMENTARY REQUIREMENTS. Retiement/Separation Beneit 1. uly acorplshedAppteation Form for Ratrement/Separaon le surance Benes 2. Sere Recor th Lene Without Pay (LWP Certain fat ie spetedtes ond ine of WP) | Decharatn of Pendeney/Mon Pendency case (PPNPC) erm dot dmtered/ rtrd shade anor ter receetf notation ‘tuyere Surender ae (Regar/Optona) ‘aly econo taned Aton Fo Retremow Separate a aan BTS Sere Record with IOP Certeaton the ond tof ‘Death Garry Acid Bath benef QeP) aeelrr ‘uly accomptzned Appleton Frm for Retrement/Separaten/e surance Benefits ‘Sere Record wth LWOP Cerca (dt he pete end tne of WOP) ‘Death erate of member lsu by Local Cal Rerr (LCR) or Pi Sats Autoety (P38) (ormety Haters Stats Ofice er NSO} rautbertatd by Philppine Constr Of if ed breed ‘Aa of Sun Legs! He Sang Spouse/Guararehip Form, Mth mnorfncapachated tilden frases th no desienatedbeneflie on) ‘Court Order or Ataf Sung Legal Hes / Suri Spouse/Guardanship Fam supported bya Report Certfiaton tse by the DSWD Offce where the miner Ineapaclated deperent hd isresdng the guaran snot te naturalparent ‘eh arteate/stsvedby LCR or PEA. valid passport or two (2) ald goverment sued Ds with sate ofbith and spate desired benefdanes /paee/sb/are not GSS member Marfage Contract o fone benef caressed by Lot PSA Pole iestationReper, Fdeath ls dueto nce ear Pere ‘ul accomplched Appation Form for Retremest/SzpraTor le sure Benes ‘Serves Record with OP Cerfeston thn the sec dates ond tie of WOP)Death Create of ment ued 1 or PA; or narnia, Pepe Canada OF Gedabroad Ati of Sunn egal Hs / Surin Souse/Guararchip For wth minor /ncapacated iden (court Onder, or Aft of Sunn Leg es / Sung Spouse/Guarartip Form supported ‘bya Report or Ceraton sued by the DSWD Ofce where he minor apace dependert tld iste the garantsnot the natural parent ‘Beh cerieates esd by LCR oc PSA or vad passport or Wo 2) ved ovement sued swith st oft ad sgroture i desksted benefits /peyee/sb/arenot GSS mente Mariage Corto feral ener ved By LR FPA,(CHECK DELIVERY RECEIPT FORM (Please read instructions below) ‘WARNING: Decor inet commision of aud, alu, alifiston, mikrepreertaton facts, any ote ind of somal inthe _sccomplshmentef ths form, or Inobtaning ary benefit under ths pleation hal be ute to dinate, eb anor crimination, ate: Name of payee/Authorized Representative/Uatson Officer (please print), (Office Address/Telephone Number Home Aédress/Contact Number: Payee Kind of Ghetk | check nuriber_[ —checkbate | Check Amount = = = Thereby affix my slgnature/ihornb mark to attest that am the rightful payee/suthorieed representatve/inion office ofthe above mentloned check/s and have receive the same to my ful satisfaction, Printed Name and Signature of Witnesses to Thumb mark: 1 2 Tram mark (tunable to tfc signature) Toasresented z 3 2 2 Application Received By: Date Released: DOCUMENTARY REQUIREMENTS PATE "AUTHORIZED REPRESENTATIVE TGASON OFFICER Duy saree Cnet baer Recap Farm | Duy azorplahed ORE T Duly scxomphhed (om corr 2. EearduMiberdsldprsportrtwo Alva! | 2, WitenAhorton sped by the payee ory notaraed | 2. Uszonctcert2 overmarcisud Is and phetcples ef the | RawerefAtomey, poyetredang hte Pipes 3. Spel Power of toey [SPH dy retatzedinthe Palppe Enbesy where the pave Is rete. the payee rg, tread 4. ead oF UMD card or wad passport or two (2) vad lnvermetsud 0s ofthe payee ard eres ae ‘Shutomlesof esane renga the Pines 5, EcanUMD caf pasport er two (2) ovement ‘sued bscftherepesereatve en shotoczpese be sore rgabroad "The wilten authorzation or Spedal Power of Attorney (SPA) should ensure thatthe folowing are present a) Date the nstrument ‘was executed ;b) Names and complete addresses ofthe pincpa and the agente) Specie transaction the principal authorizes the agent to doin hisher behalf) Signature of the prnepale] Acceptance ofthe Agent or Attorney n-act; and Acknowledgement, isa SD, AFF. Empey m/ORD vow Die ame Ae? Bes Profesional epiain Gorrasson PRET RT Past Pan b45. Sever ome Pesos WY PROT S00 Sel Peer COMA eer OCONEE Regina oT Banana Purina Pipho Rogar RTD rales ee erated ar ofa ogres (S]. Filia Frese ere heh ‘Rote: Other vad government sor Tox/Bocament maybe sceped f with ture end gneveFerma, APPLICATION FOR PRE-NEED PLANS (Pate rad Documentary Requcements atthe back) TSTRUCTIONS: Ensure atthe application form Is propery filed out and submit uly accomplished apeation form tothe nearest 651s Office. WARNING: Director Indirect commission of fraud collision, flscation, mlsepresentation of facts, or any athe kindof anomaly Inthe accomplishment ofthis form, or in ebtalring any benefit under ths application shall be subject to administrative, ell and/or erminal action. Date: (MEMBER'S INFORMATION ‘ast ame Fist fame TWidaie Name] GSIS Business Partner (BP) No Teaidence/Complete Maling Adress So) Piaceot ih ‘Gender LD renste [5] nate ‘Contact Wo. Lanaine) Calphone We. Emalradaress casa Trae Nome of pour’ (an Name FA C wtares [5] site [5] separated [EJ idowswrdoner | Name Mise name) Te ot Premera an Tian Ageemen Naniber Clesutits [I] memoratrton [1] cear ‘TYPE OF BENEFIT APPLIED FOR: [esses 1 -Avaltpent of College Edueaton Bnet Semanal ewe co Un-avaled college Ecaton Benefit (S82 ofthe Fan Agreement) TE Retun of Premiums Pid after Cancelation ofthe Pan Agreement [TEP rend or unased unis Date goes Tp reteent eet Date graduated TEI Reconciation and eques for isvnce of Carene of Fall Payment [ET others, peste speci [CI Wem TET conanced Optional but Mechaniom [EM] [EI -oestn seneioasc an Value (6Pv] or Genezs Pus Pan) Refund of Premiums Paid after Cancelation ofthe Pin Agreement TI econctation ane request for vanes of Cartete of Fullpayment T-tree spec TOT Glege education assurance Plan (EAP) T Annual Aiowance Totes, plese specy r "Trae et of of DR TTC CTO BP, TR AFR TSR RT PT ST Thereby wale and leave G5is rom, ay furiveracion, cause oT action, demand, daivages oF any cam whatsoever againitthe SIS, after receipt ofthe peyment of the above stated ela. Printed Name and signature of Witnesses ‘to Thumb marks, 2 ‘Tignature of Applicant over Printed Name "Thumb mark (itunabl to aff signature) Glam proceeds thal be electronical eredied Yo your eCord/UMID account ard may Be withdrew froth your nearest bank or ‘ATM. Ifyou have no eCorg/UMD, the proceeds wil be pold thu check. ‘Application Recelved By: Date Received: ‘TMS Reference No:DOCUMENTARY REQUIREMENTS. 1. Educhld ‘Avaliment of College Education Benefit (CEB) 2) Forint avatiment ')Duly accomplished Application Form for Pre-Need Plans 1) Course Curicuum inating the number of units and subjects tobe taken bythe scholar Certificate of Full Payment (CFP), isuedtotheplanholler 4) Offical Receiptof the tutionand other standard schcol fees €)- Registration Form with Assessment/Schedul of Fees, 2) ForSucceeding Avallments 2} Dulyaccomplshed Applicaton Form for Pre-Need Plans 1). Regstration Form with AssessmentScheduleof Fees. ©) Official Receipt ofthe tition and ather standard school fes Unavalled College Educational Benefit 3), Dulyaccomplshed Application Form for Pre-Need Plans 2) Certncat of Full Payment (CFP), issued tothe planholder ‘Unused Units/Retirement Benefit (10 years after graduatlon) 41) Dulyaccomplshed Appiation Form for Pre-Need Plans 2) Transcript Records 2, Memorial Plan ‘Enhanced Optional Ext Mechaniom (EOEM) 3) Dulyaccomplsbed Appleton Form for Pre-Need Plans 2). Certifeate of ul Payment (CFP), fssued tothe planholder Death calm 4) Duly accomplished Appcation Form fr Pre‘Need Pans 2). DeathCertfcateof planholderissued by LCR or PSA; orauthenteatedby Phippine Consular Office, dled abroad 3) Affidavit of Surviving Legal Hes/Surving Spouse/Guaranship Form 44)_Affdavtof Surviving Legal Heis/Survving Spouse/Guardanship Form supported by & Report or CCertifcation from DSWD office where the minor/Inepactated dependent ch is residng, or Court Order, Ifthe guardian snot the natural parent 5) Certfcae of Full Payment (CFP, issued othe planholder 13 College Education Assurance Plan (CEAP) Duly accomplished Application Form for Pre-Need PlansAUTHORIZATION Boo egal age, (single/married/widow/widower) andaresidentof_— do hereby name, constitute and appoint Mr./Ms, of legal age, (single/martied/widow/widower) anda resident of to be my authorized representative to do and perform the following acts, to wit (J ro file, deliver, and follow up Application for GSIS benefits and documents relative thereto; [To receive the check, fund, and/or benefit proceed from GSIS as well as to sign any document/s necessary for its release; [1 To perform any other act necessary to carry outany or all of the foregoing. Hereby giving and granting authority unto my said authorized agent / representative, whose signature appears below, full power and authority to carry out the foregoing and hereby CONFIRMING AND RATIFYING all that my said authorized agent/ representative shall do and perform by virtue hereof In witness thereof, have hereunto set my hand this at. Printed Name and Signature of Witnesses: L 2 ‘Signature of Principal over Printed Name "Thad marke (iftunable to affix ‘Sgnature) Authorized agent/representativer IDs presented: Lu 2 3 4 ‘Signature over Printed Namereget [Note Fill nal the Blanks completely and correctly, Write NONE or NOT APPLICABLE, ifit is such, Incoret or fncomplete information may enuse delay [REPUBLIC OF THE PHILIPPINES i (CITY/MUNICIPALITY OF. ss AFFIDAVIT OF SURVIVING HEIRS/SURVIVING SPOUSTY ‘GUARDIAN OF MINOR OR DEFENDENT CHILD/REN ‘After having been duly sworn ton accordance with law, 1/we hereby depose and state as follows: [Name in fll of deceased member/pensioner/retree__ Residence of deceased atthe time of death Name of offce/position ofthe deceased, Date and place of birth of the deceased Date and place of death ofthe deceased I the estate ofthe deceased under administration? If so, attach acerified true copy of appointment ofthe a ee SEE Declaration of Surviving ‘The deceased is survived by the following helrs: 8) Widow or widower ) Children (Include ali children whether legitimate, legitimated, legally adopted, or llegitimate, Attach ‘hei birth certificates and/or adoption papers In the absence of any children in any ofthe categories, the word NONE instead of the words NOT APPLICABLE should be clearly Indicated under such eategory/ies) Name Date of Binh | Orderof | __LegitimateyLegitimated/ Birth | Legally Adopted/tlegitimate ©) Father and mother of the decoased in the absence of legitimate/d children: 4) Paternal and maternal grandparents in the absence of persons under tems (8) & C)above: ©) Brothers and sisters in the absence of persons under items (2), (9, & (A) above: ‘Name Date of Bi | Order of Telationship (eg. fall Beth brother/sister: half brother/sister {) Children of deceased brothers and sisters tn the abvence of persons under ites (), (€),(d) and (@) above: ame Date of ithresents (name of widewodeoer) have not remarried, cobabited With another person, or otherwise engaged in a common-law relationship since the death of my spouse. T acknowledge that, granted, my entitlement to survivorship benefit from the GSIS wil automat permanently terminate the moment that remarry, co-habit with any relationship, whether of the same or opposite sex end whether such ¢ Thereby agree unconditionally to relmburse/returnto the GSIS, without need of demand or judicial action, all survivorship benefits that I may unduly receive after my entitlement thereto fs terminated as stated above. (name of guartisn) om the ——____" Gitte reetionstip with te chien, eg. father/mothereantfncle, ete) and ‘the legal guardian ofthe following minor and/or incapacitated child/ rem: ‘Note: Orly children wah tire Below 18 years of ela for wurcorahip Benefit under RA B91) or elas 21 years of age (f claiming for survivorship benefit under PD 1148) and/or ncapaciated ciléven, regardless of ge shouldbe included in thelist. ‘Name of MINOR oF ‘Date of Bit | Order of Bit] — Nature of Incapacity DEPENDENT child/een, Gf applicable) ‘Lam fly aware that ifthe suid child/ren is/are granted survivorship benefit by the SIS, his/her/thett entitlement thereto will automatically and permanently terminate the moment he/she/ they is/are over 18 years old or if incapacitated, upon his/her/their death. Consequently, 1 hereby unconditionally make ‘myself personally and solidarily lable withthe children for whatever survivorship benefit that the latter ‘may unduly receive from the GSIS after his/her/thelr entitlement thereto terminated as stated above. ther Declarations (Common to all Pursuant to and consistent with the declarations made above, I/we hereby authorize the GSIS to secure {information from the Philippine Statistics Authority (PSA), or other relevant government offices, or private entities to validate or check the facts herein declared, 1/we fully understand that any inaccurate and untruthful statement in this affidavit shall render me/us criminally and evily liable, /wehereby agree thatthe written statements, affidavits or all other papers called for in relation to my/our claim before the Government Service Insurance System (GSIS) shall constitute and be made part ofthis document. |/we farther agree that the furnishing ofthis document or of any other forms supplemental thereto to the aid System shall not constitute or be considered as an admission by the System thatthe deceased was ‘entitled to the benefits under CA 186 ns amended, PD 1146, PD 626 as amended, or RA $291, This should rot likewise be construed as waiver of any of GSIS rights or defenses, I/we am/are executing this affidavit to ates tothe truth ofthe foregoing statements in support of my/our application with the GSIS and for other legel purposes t may serve. Tegel Spouse - Affant Parent Affiant Parent Affant Child Affant: pogenef Child Affant Child Affiant ‘ifn CORROBORATION We, ant both of legal age, single/married, hereby confirm the foregoing statements of the caiment/s to be true and correct. We further state that we have known the deceased for around ___ years and that the deceased was buried at ‘Name and Signature of Witness Name and Signature of Witness Republic ofthe Philippines Municipality(City of ___s.s. BEFORE ME, a Notary Public for and inthis day of 20, personally appeared the following: Tame “Type of Government | Dateoflasue/Expiy | Placelssued 1D Who acknowledged thatthe foregoing statements made by them on this document are true and correct to the best of their knowledge and belief. ‘TO THE TRUTH OF THE FOREGOING, witness now my hend and seal on the date and place mentioned above, Doc. No, Notary Public Page No. Book No. ‘Series of