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HRMO Application for Retirement Benefit

COA HRMO application form for retirement benefits under RA 1616

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APPLICATION FOR RETIREMENT BENEFIT
The Honorable Chairman
This Commission

Sir:
I have the honor to apply for retirement benefit under RA 1616 effective _____________________
under the retirement law indicated below.
I.

PERSONAL DATA
For the information of the commission, I hereby declare to the best of my knowledge the
following:
Date and place of Birth:
Sex:
Civil Status:
Policy Number:
Permanent Address:
Name and Address of last Office:
Previously retired under RA
/PD
Retirement No.
On
Amount of retirement pay received: P
Amount Refunded, if any: P
LBP Account No.:
Branch Office:

II. BENEFICIARIES
Designated beneficiaries to receive retirement benefit in case of death:
NAME
RELATIONSHIP
DATE OF BIRTH

Please credit proceeds to Account No.

name of his Bank Branch

Very truly yours,
SIGNATURE OF EMPLOYEE
PRINTED NAME OF EMPLOYEE

NOTE: If member/claimant cannot sign,
thumbmark should be witnessed by two
persons. (Print name and sign)
1.
2.

III. 1ST INDORSEMENT
Officer
Date
Respectfully forwarded to the Honorable chairman, COA, Quezon City, recommending
approval of the application for retirement of Mr./Ms _______________ to take effect on _____________.
For guidance in adjudication, it is hereby certified that:
1. Last day if actual service was/ will be rendered on
2. Accrued vacation and sick leaves expired(d) on
3. Applicant has: a. been cleared of money and property accountability
b. property and money accountability in the amount of P
4. Applicant has no pending Administrative and Criminal Case;
5. Applicant has filed a Statement of Assets and Liabilities;
An up-to-date statement of Service Record indicating the inclusive dates of sick/vacation leave
of absence without pay, original copy of Ombudsman Clearance and other papers in support of this
application, as required by the Commission, are attached.
____________________
Director
 
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