Form No. 03102014-Adr - Application For Disability Retirement (Ra 660/ra 8291) printable pdf download

. 03102014-ADR

ORM

APPLICATION FOR DISABILITY RETIREMENT (RA 660/RA 8291)

(Please Read Terms and Conditions and Documentary Requirement at the back)

INSTRUCTIONS: Ensure that the application form is properly filled out and submit duly accomplished application form

to the nearest GSIS/Handling Office.

WARNING: Direct or indirect commission of fraud, collusion, falsification, misrepresentation of facts, or any other kind

of anomaly in the accomplishment of this form, or in obtaining any benefit under this application shall be subject to

administrative, civil and/or criminal action.

Date: ______________________________

I hereby apply for a retirement/separation benefit with the GSIS and declare to the best of my knowledge the

following:

Last Name

First Name

Middle Name

GSIS Business Partner (BP) No.

Complete Mailing Address

Date of Birth (mm/dd/yyyy)

Place of Birth

Contact No. (Landline)

Cellphone No.

E-mail address:

Civil Status

Gender:

Married

Single

Separated

Widow/Widower

Female

Male

If married, Name of Spouse: (Last Name, First Name, Middle Name)

Date of Marriage

I choose to avail of retirement benefits due to disability, effective ____________________________________________.

I affix my signature beside my chosen option. (Please refer to Terms and Conditions of each retirement mode on

subsequent pages)

RETIREMENT LAW

RETIREMENT OPTIONS

SIGNATURE

 Below age 60, monthly annuity payable annually for 5 years

 Aged 60 to below 63, 3-year lump sum, 2 years balance payable on the

RA 660

63rd birthday; monthly annuity after the 5-year guaranteed period

 Aged 63 and above, 5-year lump sum, monthly annuity after the 5-year

guaranteed period

 Option 1: 60 months x BMP, and BMP after 5 years

RA 8291

 Option 2: 18 months x BMP and BMP to start on date of retirement

I undertake to submit my Declaration of Pendency/Non-Pendency of Case, duly subscribed

DECLARATION OF

and sworn to before a Notary Public or Administering Officer of my agency-employer, as a

PENDENCY/ NON-

condition for the release of my retirement benefit and in compliance with Section II of CSC

PENDENCY OF CASE

Resolution No. 1302242 dated 01 October 2013.

Printed Name and Signature of

Witnesses to Thumb mark:

1. _______________________________

_________________________________________

Thumb mark

2. _______________________________

Signature of Applicant over Printed Name

(if unable to affix signature)

continue at the back page -

Form No. 03102014-Adr - Application For Disability Retirement (Ra 660/ra 8291)

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