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FORM - Request Form - 112416 - Annex D

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24 views

FORM - Request Form - 112416 - Annex D

Uploaded by

falosantiago5
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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ANNEX “D”

REQUEST FOR ACCESS TO INFORMATION


To: The Department Manager
Public Assistance Department (PAD)
Public Assistance Center, Philippine Deposit Insurance Corporation
3/F SSS Building, 6782 Ayala Avenue corner V.A. Rufino St.
Makati City 1226
Tel. No. : (632) 841-4630 to 31; Email : [email protected]

IMPORTANT REMINDERS:
1. Request form is not applicable to the following: (1) depositors/creditors/borrowers of closed banks in relation to
their respective accounts; (2) member-banks and other PDIC counter-parties in relation to their respective
transactions with PDIC; and (3) if information being requested is already posted/ published in the PDIC website
(www.pdic.gov.ph)
2. All information are required to be filled-up. Print legibly.
3. Request form should be accomplished in duplicate copies, notarized and should either be delivered personally or
mailed to the above address.
4. Fees shall be charged for photocopying, printing, certification, mailing and other reasonable costs.
5. For further details, please see PDIC’s People’s Freedom of Information Manual posted in www.pdic.gov.ph.

Full Name: (Last Name, First Name, Middle Initial) Date of Request:

Complete Address: (House No., Street, Barangay, Town/City)

Mobile/ Telephone Nos.: Email Address:

Proof of Identity (Any government-issued ID with photo. Indicate Issuing Government Office, ID No., Date
Issued/Validity)

Document(s)/Information
Requested (Use separate sheets,
if necessary)

Document/Information
Details (Description of document/
information requested.)

Purpose of Request

Mode of Release of Please check one:


Document/Information (How [ ] Pick-up
would you like to receive the [ ] Mail/Courier
information?) [ ] Email (if requested information/document is readily available in
electronic format)
[ ] Fax (Fax No.: ________________________)
(not available for voluminous documents)

PDIC Request for Access to Information Form Page 1 of 2


I hereby certify that this Request for Access to Information is made in good faith, that the
personal information provided herein are true and correct and that the information requested shall not
be used for any purpose contrary to law, or to harass any person, to commit any injustice, or any
purpose other than the purpose(s) declared above.

_______________________________________
Signature Requesting Party

SUBSCRIBED AND SWORN to before me this ______________ day of ____________, affiant


exhibiting to me his/her photo-bearing ID _____________________ numbered _________________ issued on/
valid until ________________________.

Notary Public

Note: Request for access to information shall be denied or refused acceptance on any of the following grounds: (a)
when the information is not considered as part of the public records of the Corporation; (b) when information is
subject of a pending case, in which instance, request for information may be coursed through the courts; (c) when
the reason for the request is contrary to law; (d) when the same is considered as personal information subject to
protection as provided under Section E (3); (e) when the request is unreasonably identical or substantially similar to
an earlier request by the same person that has been acted upon by the Corporation; and (f) when the information
falls under any of the exceptions enshrined in the Constitution, existing law or jurisprudence, including the inventory
of exceptions circularized by the Office of the President as determined to be applicable to the Corporation.

---------------------------------------------------------------------------------------------------------------------------
- To be accomplished by PDIC personnel –

RECEIVING UNIT RESPONSIBLE UNIT APPROVING AUTHORITY

DATE RECEIVED: VALIDATION: ACTIONS TAKEN:

TIME RECEIVED: [ ] Compliant [ ] Granted


[ ] Clarification:________________ [ ] Denied*
RECEIVED BY: __________________________________ [ ] Extension*
[ ] Additional Information: ______ (see separate Notice of Denial/
_______________________________ __________________________________ Extension)
Name, Position and Signature [ ] Other: ______________________
__________________________________
REFERENCE NO. ASSIGNED:
______________________________
_______________________________ Name, Position and Signature
______________________________
Name, Position and Signature
REFERRED TO (Responsible Unit):
______________________________ Date: ___________________
Date: ___________________
Date referred: ________________

IF REQUEST IS GRANTED:
RELEASED ON: _____________________________

RELEASED BY: ___________________________


Name, Position and Signature

PDIC Request for Access to Information Form Page 2 of 2

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