Beruflich Dokumente
Kultur Dokumente
E-Form 1
LHF 01/18/10
RETIREMENT
BENEFITS
DISABILITY
BENEFITS
DEATH
BENEFITS
First Name
Middle Name
PERIOD OF EMPLOYMENT
1. ____________________________________________________________________________________________
___________________________________
2. ____________________________________________________________________________________________
___________________________________
MAILED
CLAIMED AT PERAA
BY:
Disability Benefits
_______________________
Date
Death Benefits
IMPORTANT: To claim check, please present 2 valid identification cards (e.g., school ID, PRC license, Driver's license, SSS ID, BIR ID, etc).
CHECKLIST OF REQUIREMENTS
ADM 4-A
Certificate of Employment with inclusive dates (indicating the first and last day of service with the school).
Certification from the school that the employee/member is officially retired from the school**.
Photocopy of Birth Certificate issued by the Local Civil Registrar or Baptismal Certificate. In the absence of these documents,
please submit a certification from the Office of the Civil Registrar General or the Local Civil Registry
Office that no records are available AND an Affidavit of Birth attested by two disinterested persons.*
Notarized Release and Quitclaim Form* (sample form attached).
Photocopy of any two (2) valid ID cards (e.g. School ID, PRC license, SSS ID, BIR ID, Driver's license) with picture and clear
signature. The photocopy should also be signed by the claimant.
Multi Purpose Loan (MPL) certificate of loan payment
Photocopy of approved SSS Disability Claim
Physician's Certification of PERMANENT TOTAL DISABILITY (PTD)
School's acceptance letter of the Physician's Certification of PTD of member
Special Power of Attorney if business is to be transacted by a representative, together with two (2) valid Identification Cards (with
picture and signature) of the member and representative.
Others _______________________________________________________________________________________
_______________________________________________________________________________________
Note: Blue form and Certificate of Employment should be signed by the authorized signatory of the school.
* Notarized by a Notary Public only.
** Requirement in availing tax exemption of benefits under RA 4917
INSTRUCTIONS
1. Submit only one copy of a complete application. Avoid erasures or alterations in your application and supporting
papers.
2. Fill out all applicable blanks and check all appropriate boxes. Print or type all entries.
3. Submit the complete form to your employer for signature of the school official/representative authorized to approve
benefit claims. ONLY the names and signatures of the school officials/representatives appearing on the Specimen Signature Card
submitted by the school will be honored.
4. Submit the complete form and other requirements as indicated above to PERAA.
Note: To claim your checks, please present the following:
1. At least 2 Identification Cards (e.g. laminated company ID, new SSS ID, new BIR ID, driver's license, PRC ID,
latest passport)
2. Special Power of Attorney in case a representative will claim the check & a photocopy of representative's ID cards.
3. Others _________________________________________________
_________________________________________________
WITNESS WHEREOF, I have hereunto set my hand this _____ day of ____________, 20___ at
______________________, Philippines.
___________________________________
Printed Name and Signature of Affiant
_______________________________
Printed Name and Signature
This document shall be valid only upon receipt of my PERAA check payment.
ACT'L 01/06
E Form