APPLICATION FOR RETIREMENT/ I SEPARATION/LIFE INSURANCE BENEFITS. nf 26/2023 Form No, 063000477 Mer Gsis | INSTRUCTIONS: nauro that the application Torn f properly fifod oul and Bubimit duly nesamplishod application fori lo tha nonrast GSIS Offa, WARNING: Director indiract commission of fraud, colliston flscation, misropresontation of facts, or any ethor kind ff anomaly n tho accomplishmont of this form, of in obtalning any benofl under th applleaon shell bo sulject to rdministalvo, el andor eriminal action, bate: | norety apnly for a ratiramentUseparationffe insurance benoft with tho QSIS and doclaro to the bost of my knowiedgo tho fallow Ci ama Completa Maling Address Dato of Bit Tamil) | Conia No: ening) ~ (]Maviod [2] Singlo ! | Esoparstod [7] widowor Widowor | Raton | have the honor to apply for |[-}Retromant bonotts undor tho ratrmant mode waked below, afoava 1 oaldo mycin | { RETIREMENT ies 5 Hr Race __RETIREMENT OPTIONS i 660°" [2] elow age 66, msonthly annully payable annually Tor 6 yonre [5 Aged 60 to below 69, 8-yoar lump sum, 2 years balance payabla on the (63% iinhday; monthly annuly afer tho 6-year guarantood period [21 Aged 63 and abovo, 5-yoar lump sum, monthly annuity ator the 6-yoar ‘guaranteod poriad, bp 1146") OY inioaiate Monthly Ponsion | [7.60 months x Basie Monthly Ponsion (BMP) and BMP altor 6 yoars | ieansor (Option Fone KR woos EJoption 2: 18 months x BMP and BMP to start on dato of rotirement Sa | 8h 010") [Rot 6f Romani Premiums (Roiamant grat to ba pad by wat | APPLICATION | T'yoi opt 06 tale dar a rotront Sehomo wih ak TrimoaatS monthly pansion, you may sot FoR CLASP | your outstanding loan obligation on instalimont basis undar the Choleo of Loan Amotizalion | Scheduo far Ponsionors (CLASP) program. Tho romalning balance of your outstanding obligate | ‘shall bo rostncturod as a loan with an inorost rato of 10% por annum eompouncad annually (pace). | | Employor) | Ploaso indicate your choleos bolow: {As payment for my outstanding obligation, ploase deduct frm the procoods of my rotoment ‘benefit the amount oquivalant to: SIGNATURE 1%, alnco | ain not avalling the CLASP , romaiing balance af 25% ahall bo pald through CLASP 150%, romaining balance of 60% shall bo pald through CLASP. 25%, romalning balance of 76% shall be pald through CLASP. Proterrad copaymant torm forte romalning balance: It yor 2 yoors Hs tons 1 conti that | havo road and fuly unddorstood tho PENSIONER RESTRUGTURED LOAN (PRL) Terms and Conditions and undortako fo comply with thom. Pursuant to Ropublio Act (R.A,) No. 9510, cothorwiso known as tho “Croc Information Systom At’, and Re Implomonting los nn Reguitos (RR), | horoby acknowlodgo and consont to: 1) tho regular submission and disclosure of my basic Gredit data and updates thoroon fo tho Croat Information Corporation (C10): and 2) tho sharing of | ‘my basie crodit data wh fanciors authorized By tho le, nnd eredit reporting agonlae ane! Outsource ‘nities duly accredited by tho CIC, subjoct {0 the provisions of R.A, No. 9510, ts IRR and othor rolovant laws and regulations, NTARY REQUIREMENTS A. Rotiroment/Separation Benofit 1. Duly accomplished Application Form for Retiroment/Separation/Life Insurance Benefits, 2. Service Record with Leave Without Pay (ILWOP) Certification (indicating the specific dates and time of LWOP) DOCUMILISEPARATION BENEFIT (RA 6204) offoctivo (mmiadlyyyy) ———_—_____——~ | ~~ {slow 60 years old wih fous than 16 years In sorvico (Cash Benofit payable et ‘age 60) [Eboow 60 years old with more then 16 yosrs In aorvice (Cash Benefit payablo upon ‘soparation and monthly pension upon reaching ag0 60) [Eto yours old and above with lass than 16 yours In service (Gath Geneft payablo ‘nsmadltely) | cifaton af | Vunaovae wo balmy Becton of Ponda, Pandey of ase, att Beclration of | Guces to Dotore ‘a Notary Publ or Adminstring Officer of my agonoy-employr, a8 a colin rane ney at aso forty eloase of my retroment baal and in companeo wih Suction I of CSC Resolaion No. | 8° | 202242 dated 4 Ootobor 2018 | Pew arto Tasranco: TLICompuisow | Loner Pay Wot CEASED: oe Wane type spllad for FliiunyBerei {Gash Surrender Valua/Terminaton Valo, in vow of my tromontettoctve Tesignatlon/saparation fam tho govornmonl aonice Oh —_ pate othor reasons Doath Serotits: Dato of Doat Acodontal Death Beneft (ADB) Capplicble Yr CMILEPVOpVonal pois) itis understood! that tho ontire outstanding balaneo of my polley 28 woll as the arroarages and balancos of my fthot Toans and aegountabllitios with the @SIS wheh ara due and damandablo shall ba daducted from tho sald bonofit pursuant to Artiolos 1231 and 1270 of the Civil Cod of the Philippines, RA 6294 and tho oxisting Printod Name and Signature of Witnassos to Thumb mark: Cas ea ate 2 Tham mark Tipalre oFAppennt aver Frntaa Name (unable aah lg iain progeads shall bo eloctronieally crodfod To your oOarVUIND account and may bo withdrawn bani or ATM. IryoU have no eGare/UMID, the procoads wil bo pald through chock. OUT BY HEAD OFAC | bald 2 ea = sa | iospacl ford to GBIS Wis appleatan Tor rlramonseparslpalifonsranco bani wih our rocormondallon forapproval, kis hereby certified that tha applicant (Pinca a chock (¥) mark on the pertinent box enly) 4, [Enos no paneting edminlatravoreriminal caso, 2, (Elnas penaing administralvorcriminal caso at 5 Ae ' docelod administrativo caso with 4 = (Pioase ‘of Docsion) (Plonge attach cortfied copy of Docision) jlleatlon for gratuity bonellt has boon has a doeided oriminal cage with as Is applying for Rofund of Promlurie undar RA 1618 and ‘approved by ths Office, ‘vor prod name of the Hoa of Agony Dato signod: ‘orhisMhar Authorized Endoraing Ofer Appation Received By: Date Rocovoc!