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FM-DBB-APF-D01 Death Claim Application Form
OWWA application form for death claim
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OVERSEAS WORKERS WELFARE ADMINISTRATION
SOCIAL BENEFIT
(DEATH CLAIM)
Regional Welfare Office ____________________
Applicant No._________________
CLAIMANT’S DATA
Name of Claimant:__________________________________________________________________________________
(LAST)
(FIRST)
(MIDDLE)
Sex:_______ Civil Status:________ Birthdate:_________________Birthplace:________________________ Age:_______
Permanent Address:
Relationship to OFW:
______________________________________________________________________________
______________________________________________________________________________
_______________________________________ Tel/CP No.:_____________________________
OFW DATA:
Name of OFW:______________________________________________________________________________________
Birthdate:________________________________________ Birthplace:_________________________________________
Agency:__________________________________________ Employer: ________________________________________
Position:_________________________________________ Jobsite:___________________________________________
Date of latest OWWA contribution:___________________________________________Duration:___________________
Cause of Death:___________________________ Date of Death:___________________ Place of Death:______________
_____________________________________
SIGNATURE OF CLAIMANT
__________________________
DATE
DOCUMENTS SUBMITTED:
(
(
(
(
) Death Certificate
) Marriage Certificate (NSO)
) Birth Certificate (NSO)
) CENOMAR (NSO)
(
(
(
(
) Official Receipt of Funeral Expense
) Accident/Police Report
) Passport/Seaman’s Service Record Book
) Others
RECEIVED BY:__________________________________________
Date: __________________________________
VERIFICATION
With previous availment
Without previous availment
By:_____________________________ Date:__________________
EVALUATION
By: ___________________________________
Date:_________________________________
RECOMMENDATION:
APPROVED:
Applicant is entitled to P________________
____________________________________
CHIEF, PSD
________________________
Date
_______________________________________________
RWO DIRECTOR
__________________________
Date
Rev: 00
UNDERTAKING
I, ___________________________________________, of legal age, ______________,
Filipino citizen and a resident of __________________________________________________
____________________________________________________________________________
After having been duly sworn to in accordance with law, do hereby depose and say:
1. That, I am the beneficiary and claimant of _________________________________
accruing from _______________________________________________________;
2. That, for whatever benefits or amount that I may receive from the Overseas Workers
Welfare Administration (OWWA), I hereby take full responsibility for my action and hereby
undertake to absolve the OWWA from any liability that may arise from its release of said
claim;
3. That, likewise, in the event that any person who has a better right to my said claim would
appear, I undertake to return or pay any amount that I shall receive in favor of the person;
4. That, I am executing this affidavit for the purpose of attesting to the truth of the foregoing
and in order to support my claim for __________________________________________
________________________________________________________________________.
In witness hereof, I have hereunto set my hand this _______ day of __________________
20______ at _______________________________________________.
_____________________________
Claimant
Subscribed and sworn to before me this _______________ day of _______________________
20_________ at ______________________________.
____________________________
Administering Officer
