Check Alteration And Replacement Form (Carf)
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. 03122014-CARF
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CHECK ALTERATION AND REPLACEMENT FORM (CARF)
(Please read instructions below)
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 and/or criminal action.
GSIS ID No./Policy No./Pensioner’s ID No.
Member
Pensioner
Others ____________________________________
Telephone No. (Landline)
Payee of Check to be Replaced: ________________________________________________________
If survivor/beneficiary is filing request, indicate full name (First Name, Middle Initial and Surname)
Cellphone No.
_
________________________________________________________________________________________
Residential Address of Applicant
E-mail Address
Agency Name/Address (if active member)
Check Particulars
Reason for Replacement
Lost/Stolen
Type of Check:
Retirement
Life Claim
Dividend
Others _________________________________________
Stale
Erroneous Name
Check No. ___________________________
Check Date _______________________________
Others
Check Amount _______________________
Drawee Bank _____________________________
______________________________________________________________
______________________________
Signature of Applicant over Printed Name
Date Filed
DOCUMENTARY REQUIREMENTS
FOR CHECK RELEASED TO PAYEE
FOR CHECK WITH GSIS
a. Lost
a. Lost
1) Check Alteration and Replacement Form (CARF);
1) Check Alteration and Replacement Form (CARF);
2) Affidavit of Loss
2) Notarized
Incident
Report
prepared
by
the
b. Damaged
concerned personnel with the custody of the check,
1) Check Alteration and Replacement Form (CARF);
duly noted by the DC, Officer I or Extension Head,
2) Physical Check
whichever is applicable
3) UMID, eCard or ay two (2) prescribed GSIS valid IDs
b. Damaged
of claimant/s
1) Physical Check
c. Deceased Payee
c. Deceased Payee
1) Check Alteration and Replacement Form (CARF);
1) Check Alteration and Replacement Form (CARF);
2) Physical check
2) Physical Check
3) NSO Death Certificate if no claim for funeral benefit has
3) NSO Death Certificate if no claim for funeral benefit has been
been filed;
filed;
4) Notarized Proof of Surviving Legal Heirs if no claim for
4) Notarized proof of Surviving Legal Heirs if no claim for
survivorship benefit has been filed;
survivorship benefit has been filed;
5) NSO Birth and Marriage Certificate of Legal Heirs (for
5) NSO Birth and marriage Certificate of Legal Heirs (for spouse
spouse and married female heirs);
and married females heirs); and
6) UMID, eCard or any two (2) prescribed GSIS valid IDs of
6) UMID, eCard or any two (s) prescribed GSIS valid IDs of
claimant/s; and
claimant/s;
7) Notarized deed of extra judicial settlement designating
one payee.
d. Wrong Payee Name
1) Check Alteration and Replacement Form (CARF);
d. Wrong Payee Name
2) Physical Check;
1) Check Alteration and Replacement Form (CARF);
3) NSO Birth Certificate of the Payee; and
2) Physical Check;
4) UMID, eCARD of any two (2) prescribed GSIS valid IDs
3) NSO Birth Certificate of the Payee; and
of claimant/s
4) UMID, eCARD of any two (2) prescribed GSIS valid
IDs of claimant/s
e. Stale Check
1) Check Alteration and Replacement Form (CARF); and
e. Stale Check
2) Physical check
1) Check Alteration and Replacement Form (CARF);
2) Physical check
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