Application For Unemployment Benefits Under Ra 8291 printable pdf download

Application For Unemployment Benefits Under Ra 8291

. 03102014-UNEM

ORM

APPLICATION FOR UNEMPLOYMENT BENEFITS UNDER RA 8291

(Please Read Terms and Conditions and Documentary Requirements 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 unemployment benefits 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)

Retirement/Separation Benefits Previously

Availed (if applicable):

____________________________________________________________

RA 660

RA 1616

Date of Marriage: _______________________________________________

PD 1146

RA 8291

I choose to avail of unemployment benefits under RA 8291, effective _________________________________.

(Please refer to Terms and Conditions of each retirement mode on subsequent pages)

DECLARATION

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

OF PENDENCY/

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

NON-PENDENCY

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

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)

Claim proceeds shall be electronically credited to your eCard/UMID account and may be withdrawn from your

nearest bank or ATM. If you have no eCard/UMID, the proceeds will be paid thru check.

Back page must be filled-out

Application For Unemployment Benefits Under Ra 8291

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