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Pensioner Claims Application Form

BJMP application form for pensioner claims

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DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT
BUREAU OF JAIL MANAGEMENT AND PENOLOGY
National Headquarters
144 Juco Bldg., Mindanao Avenue, Project 8, Quezon City
————————————————————————————————————-

CLAIMS APPLICATION FORM
PERSONNEL DATA
NAME

(SURNAME)

(GIVEN NAME)

I

ADDRESS (NUMBER & STREET)

DATE OF BIRTH (MM/DD/YYYY)

(BARANGAY)

I
I

(MIDDLE NAME)

I

BADGE NUMBER

(TOWN/DISTRICT)

I

PLACE OF BIRTH (TOWN/DISTRICT)

(CITY/PROVINCE)

I

(CITY/PROVINCE)

I

POSTAL CODE

I
I

CIVIL STATUS

CLAIM TYPE
RETIREMENT PENSION
RETIREMENT WITH OPTION FOR 3 YRS LUMP SUM
TERMINAL LEAVE BENEFITS
MONETARY DEATH CONTRIBUTION

PD 1184 (LIFETIME PENSION/MONTHLY ANNUITY)
SURVIVORSHIP PENSION
SEPARATION GRATUITY BENEFITS

Legend:




SPOUSE

PD 1184 (LIFETIME PENSION/MONTHLY ANNUITY/) - for Permanent Total Disability (PTD) and Death in the Line of Duty
SEPARATION GRATUITY BENEFITS - for personnel who were granted disability in the line of duty
MONETARY DEATH CONTRIBUTION - subject to the rules on Voluntary Death Contribution
(SURNAME)

(GIVEN NAME)

I

DEPENDENT CHILDREN
(unmarried, below 21 yrs old)

DATE OF BIRTH

CIVIL STATUS

CIVIL STATUS

ADDRESS

__________
__________
__________
__________

CHECK APPLICABLE COLUMN
LEGITIMATE

1. ________________________
2. ________________________
3. ________________________
4. ________________________

(MIDDLE NAME)

I

______________________
______________________
______________________
______________________

ILLEGITIMATE

______________
______________
______________
______________

(use separate sheet if necessary)
(SURNAME)

NAME OF CLAIMANT
ADDRESS (NUMBER & STREET)

I

DATE OF BIRTH (MM/DD/YYYY)

I

(BARANGAY)

I

I

(GIVEN NAME)

(TOWN/DISTRICT)

(CITY/PROVINCE)

I

(MIDDLE NAME)

I
I

POSTAL CODE

ID picture taken within
the last 6 months
3.4 cm x 4.5 cm
(passport size)
Computer generated
or Xerox copy of
picture is not
acceptable

RELATIONSHIP TO JAIL PERSONNEL

CHECKLIST OF REQUIRED DOCUMENTS FOR RETIREMENT AND SEPARATION BENEFITS
BJMP CLEARANCE
CERTIFICATE OF NO-PROPERTY ACCOUNTABILITY
RETIREMENT /SEPARATION ORDER
CERTIFICATE OF NO-MONEY ACCOUNTABILITY
SERVICE RECORD
CERTIFICATE OF NO PENDING CASE (except for TLB)
ORIGINAL APPOINTMENT IN THE GOVERNMENT SERVICE
LATEST ATTESTED APPOINTMENT

OMBUDSMAN CLEARANCE (except for Burial and Death claims and TLB)
LATEST SWORN STATEMENT OF ASSETS AND LIABILITIES

LATEST LONGEVITY PAY ORDER

LANDBANK ACCOUNT NUMBER

LATEST PAYSLIP AND CERTIFICATE OF LAST PAYMENT
FAMILY DOCUMENTS, TO PROVE RELATIONSHIP WHEN APPROPRIATE (NSO COPY)
ADDITIONAL REQUIREMENTS FOR TERMINAL LEAVE BENEFITS (TLB)
COMMUTATION ORDER OR APPROVED CSC FORM 6

ADDITIONAL REQUIREMENTS FOR PTD AND DEATH IN THE LINE OF DUTY
ADJUDICATION BOARD RESOLUTION

CERTIFICATE OF EARNED LEAVE CREDITS
REQUIREMENTS FOR MONETARY DEATH CONTRIBUTION
DEATH CERTIFICATE OF THE PERSONNEL (NSO COPY)

SPOT/INCIDENT REPORT

FAMILY DOCUMENTS TO PROVE RELATIONSHIP (NSO COPY)

OFFICIAL RECEIPT TO PROVE THAT CLAIMANT SHOULDERED THE EXPENSES
FOR THE BURIAL OF THE DECEASED PERSONNEL (when necessary)

———————————————————————————————————————————————————————————————————————————————

I CERTIFY under pain of perjury or falsification that all the above information are true and correct:

____________________________________________
(APPLICANT’S SIGNATURE OVER PRINTED NAME)

Verified by:
_____________________________________________

_________________
DATE

Remarks:
___________________
Date

Instruction: Please fill up the appropriate boxes . Use separate sheets if necessary.
DIRECT DEPOSIT AUTHORIZATION
I/We hereby authorize the Finance Service Unit (FSU), BJMP-NHQ, to directly deposit the amount of my/our claim at
my/our Landbank Account No._____________________________.

Claimant/Payee:

Claimant/Payee:

________________________________
Signature Over Printed Name

_______________________________
Signature Over Printed Name

Specific Instruction: All beneficiaries who assign their right to receive their share in the survivor’s pension and/or monthly annuity and/or other
benefits to a representative who is also a beneficiary must fill up and sign this authorization.

AUTHORIZATION TO REPRESENTATIVE PAYEE
I/We hereby authorize ___________________________________ to receive my/our share in the survivor’s pension
and/or monthly annuity and other benefits as heir/beneficiary/s of _____________________________________.

Claimant/Payee:

Claimant/Payee:

________________________________
Signature Over Printed Name

_______________________________
Signature Over Printed Name

Specific Instruction: Parents/natural guardians/appointed guardians of children below 18 years old must fill up this application and prove his/her
authority to act as the legal representative of the ward–beneficiary/s.

APPLICATION AS REPRESENTATIVE PAYEE

I, as guardian of _____________________________________, who is an heir/beneficiary/s of _________________
____________________, hereby applies as payee to receive for and in his behalf his share in the survivor’s pension/monthly
annuity and other benefits from the BJMP .
Applicant:
_______________________________
Signature Over Printed Name

BJMP CLEARANCE
(FOR RETIREMENT CLAIMS AND OTHER SEPARATION BENEFITS)
NAME OF PERSONNEL:
_______________________________________________________________________________
__
RANK
SURNAME
FIRST NAME
MIDDLE NAME
BADGE NO
ADDRESS:
_______________________________________________________________________________
__
NUMBER & STREET
BARANGAY
TOWN/DISTRICT
CITY/PROVINCE
PLACE OF LAST ASSIGNMENT:____________________

DESIGNATION:____________________

DATE OF RETIREMENT/SEPATION:________________

GENERAL ORDER NO._________________

OFFICES

SIGNATURE OF
AUTHORIZED OFFICIAL

REMARKS

DIRECTORATE FOR HRRM

DIRECTORATE FOR LOGISTICS

DIRECTORATE FOR COMPTROLLERSHIP

Instructions:

1.
2.

The Directorate for HRRM shall require the presentation of the retirement/separation order prior to signature.

3.

The Directorate for Comptrollership shall require the prior issuance of the Certificate of No Money Accountability and Certificate of Last
Payment by the Chief, Finance Service Unit prior to signature.

The Directorate for Logistics shall require the prior issuance of the Certificate of No Property Accountability by the NHQ Supply
Accountable Officer prior to signature.

RECOMMEND APPROVAL:

___________________________________
Chief of Directorial Staff

This certifies that the personnel whose name and badge number
appears above is cleared of all property and money accountability in the
BJMP.

___________________________________
Chief, BJMP
___________
Date

6. Separation

SEPARATION
Pursuant to Section 41 of PD 1184 and Sections 73 of Republic Act 6975,
SJO2 ABRAHAM W BARRIOS of BJMP-NHQ, who died in the line of duty is hereby
separated from the Bureau of Jail Management and Penology service effective
20 January 2010. Subject personnel shall receive benefits under the said laws with
3rd Longevity Pay pursuant to section 71 of RA 6975.
7. Separation thru Permanent Total Disability

SEPARATION
Pursuant to Section 41 of PD 1184 and Sections 73 of Republic Act
6975, JO2 MELCHOR A CAGUIOA of BJMP-NHQ, having incurred Permanent
Total Disability in the line of duty is hereby separated from the Bureau of Jail
Management and Penology service effective this date. Subject personnel shall
receive benefits under the said laws with 3rd Longevity Pay pursuant to section 71
of RA 6975.

FORMAT OF GENERAL ORDERS FOR RETIREMENT/SEPARATION
FROM THE SERVICE
1. Compulsory

RETIREMENT
Pursuant to Sections 39 and 74 of Republic Act 6975, SJO4 Lorenzo P Cutiyog of
BJMP-CAR, is hereby compulsorily retired from the Bureau of Jail Management and Penology service effective 05 September 2010. Subject personnel will receive retirement benefits
corresponding to the rank of INSPECTOR having held the rank of Senior Jail Officer 4 in
permanent status for over one year with 5th Longevity Pay pursuant to Section 71 of RA
6975.
2. Optional

RETIREMENT
Pursuant to Sections 40, 71 and 74 of Republic Act 6975, SJO4 Sabtal S Asakil of BJMP-ARMM, is hereby granted optional retirement from the Bureau of Jail
Management and Penology service effective 01 August 2010. Subject personnel
shall receive retirement benefits corresponding to the rank of INSPECTOR having
held the rank of Senior Jail Officer 4 in permanent status for over one year with
4th Longevity Pay pursuant to Section 71 of RA 6975.
3. Compulsory thru Permanent Total Disability

RETIREMENT
Pursuant to Section 41 of PD 1184 and Sections 73, 74, and 75 of
Republic Act 6975, J/CINSP PEDRO D BANAG of BJMP-NHQ, having incurred
Permanent Total Disability in the line of duty is hereby compulsory retired from
the Bureau of Jail Management and Penology service effective 24 January 2010.
Subject personnel shall receive benefits under the said laws with 5th Longevity Pay
pursuant to section 71 of RA 6975.
4. Compulsory thru Death in the Line of Duty

RETIREMENT
Pursuant to Section 41 of PD 1184 and Sections 73 and 74 of Republic
Act 6975, J/INSP JUAN B DELA CRUZ of BJMP-NHQ, who died in the line of duty
is hereby compulsory retired from the Bureau of Jail Management and Penology
service effective 31 December 2009. Subject personnel shall receive benefits under
the said laws with 5th Longevity Pay pursuant to section 71 of RA 6975.
5. Optional thru Partial or Temporary Disability

SEPARATION
Pursuant to Section 41 of PD 1184 and Sections 73 of Republic Act
6975, JO2 MELCHOR A CAGUIOA of BJMP-NHQ, having incurred Partial/
Temporary Disability in the line of duty is hereby separated from the Bureau of Jail
Management and Penology service effective this date. Subject personnel shall
receive benefits under the said laws with 3rd Longevity Pay pursuant to section 71
of RA 6975.

FORMAT OF GENERAL ORDERS FOR COMMUTATION OF LEAVE CREDITS
1. Commutation

COMMUTATION
Pursuant to Executive Order No. 292 dated 22 July 1987 and Sections
73 of Republic Act 6975, JO2 MELCHOR A CAGUIOA of BJMP-NHQ, is hereby
granted commutation of accumulative leave of 762.78 days (381.39 days vacation
leave and 381.39 days sick leave) effective 20 January 2009 with 3rd Longevity Pay
pursuant to section 71 of RA 6975.
 
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