DILG-NBOO

DBC Form 001

APPLICATION FOR BARANGAY OFFICIAL’S DEATH BENEFIT CLAIM

Instructions: This form shall be accomplished by the claimants and submitted

immediately to the DILG HUC/ICC/CC/Municipal Office.

NAME OF BARANGAY OFFICIAL: ________________________________

POSITION: ________________________________

BARANGAY: ________________________________

CITY/MUNICIPALITY: ________________________________

PROVINCE: ________________________________

DATE OF ELECTION/
APPOINTMENT: ________________________________

DATE OF DEATH: ________________________________

________________________________________

SIGNATURE OVER PRINTED NAME OF CLAIMANT

_________________________

DATE ACCOMPLISHED

ATTACHMENT:

Certified True Copy of Death Certificate

DILG-NBOO
DBC Form 002

TRANSMITTAL LETTER

February 02, 2018

RUPERTO B. MARIBBAY, Jr., CESO V

Provincial Director
DILG Cagayan
Tuguegarao City, Cagayan

Sir:

I am submitting herewith the application for death benefit claim of the beneficiary of the following
deceased barangay official:

Name of Deceased Name of

Position Barangay
Barangay Official Beneficiaries
Noraline V. Gapas- Wife
Sangguniang
Vincent D. Gapas Pinas, Claveria Noven Lord V. Gapas- Son
Barangay Member
Jezrel Vincent V. Gapas- Son

Very truly yours,

LUIS E. UDANGA
OIC-MLGOO

ATTACHMENT:

Accomplished Application Form

Certified True Copy of Death Certificate