Republic of the Philippines
SOCIAL SECURITY SYSTEM/GOVERNMENT SERVICE INSURANCE SYSTEM
APPLICATION FOR DEATH/DISABILITY/RETIREMENT BENEFIT
(Under the Portability Law)
(Please Use Black Ink Only)
NAME OF MEMBER: Last Name First Name Middle Name SS NUMBER:
CLAIMANT'S ADDRESS: GSIS MEMBERSHIP NUMBER:
CIVIL STATUS BANK NAME, BRANCH AND ADDRESS:
WITNESSES TO THUMBMARK: SAVINGS ACCT. NO.
(SIGN OVER PRINTED NAME)
CLAIM TYPE:
1. _________________________________________
Retirement/Old Age
Death/Survivorship
THUMBMARK PRINTED NAME AND SIGNATURE
(in lieu of signature) OF MEMBER/CLAIMANT 2. _________________________________________ Disability
For Old Age/Retirement/Disability Claim Only For Death/Survivorship Claim Only
DATE OF BIRTH: PLACE OF BIRTH:
DATE OF DEATH:
CERTIFICATION OF SEPARATION FROM LAST EMPLOYER (For Old Age/Retirement Claim Only)
ADDRESS OF EMPLOYER:
Thi iis tto certify
This tif th
thatt th
the E
Employee
l named
dhherein
i was separated
t d
from our employ on:
PRINTED NAME & SIGNATURE OF AUTHORIZED REPRESENTATIVE:
(Exact date of separation)
NAME OF EMPLOYER: POSITION/TITLE:
SSS DATA
QUALIFIED DEPENDENTS:
NAMES OF LEGITIMATE CHILDREN DATE OF BIRTH ADDRESS
1.
2.
3.
4.
5.
I CERTIFY:
1. That the above-mentioned minors are under my care and custody;
2. That I am competent to receive in behalf of the said minors the amount due them as dependents of the subject member
of the Social Security System;
3. That I have not abandoned, neglected or refused to support said minors, nor caused them to commit offenses against
the law;
4. That I will immediately notify the SSS should any of the above-listed minors die, marry or become gainfully employed;
and
5. That none of the aforesaid minors are married or employed with a salary of P300.00 or more a month.
Signature Over Printed Name
CLEARANCE (For SSS Use Only)
REMARKS: CLEARED BY: DATE:
NO OTHER CLAIM FILED
SSS / GSIS CERTIFICATION FOR:
This is to certify that the above member has: Printed Name and Signature of Certifying Official SSS/GSIS
___________ total number of contributions
from ___________ to ____________ Information
Position/Title
___________ total number of creditable years of service Certification
Republic of the Philippines
SOCIAL SECURITY SYSTEM/GOVERNMENT SERVICE INSURANCE SYSTEM
APPLICATION FOR DEATH/DISABILITY/RETIREMENT BENEFIT
(Under the Portability Law)
(Please Use Black Ink Only)
NAME OF MEMBER: (Last Name, First Name, Middle Name)
For Retirement/Old Age/Disability Claim Only
GSIS DATA
1ST INDORSEMENT
(Date)
(O f f i c e )
Respectfully forwarded to the President and General Manager, GSIS, Manila recommending approval of the
application for retirement of _________________________________________________________ to take effect on
_______________________________.
For guidance in adjudication, it is hereby certified that:
1. Last day of actual service was/will be rendered on _____________________________________;
2. Accrued vacation and sick leaves expire(d) on ___________________________;
3. Applicant has:
a. been cleared of money and property accountability;
b. property and money accountability in the amount of P_____________________;
4. Applicant has no pending Administrative and criminal case(s);
5. Applicant has filed his/her Statement of Assets and Liabilities;
An up-to-date statement of service record indicating the inclusive dates of sick/vacation leaves of absence without
pay, original copy of Ombudsman Clearance and other papers in support of this application, as required by the System are
attached.
Printed Name and Signature of Indorsing Official
Title/Position
MEMBER'S SERVICE RECORD:
Inclusive Dates Annual
Designation Status Name of Office & Station LAWOP Remarks
From To Salary
CERTIFIED CORRECT:
Printed Name and Signature of Head of Office Official Designation Date
or His Duly Authorized Representative
CERTIFICATION OF ENTITLEMENT/ELIGIBILITY N.B.
The above member is:
NOT ENTITLED to the
1. If there are periods of contractual service,
ENTITLED to the benefit
under the Portability Law benefit under the Portability please attach contract of employment.
(RA7966) Law (RA7966)
2. In claims for death/survivorship benefits,
PROCESSED AND Signature: Ombudsman Clearance is not required.
APPROVED BY:
Date:
-2-
