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Optional

PNP compulsory application form for optional

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PNP RETIREE
( OPTIONAL )
Note:This form is deemed not submitted if some spaces are not filled up.
Put N/A as the case may be. Non-submission will hold the release of
the subsequent regular pension. This is for the conduct of inventory
of pensioners nationwide.
1. Principal Pensioner Personal Data:
LAST NAME
FIRST NAME
2. Pensioner’s
Rank

MIDDLE NAME

3. Date of Birth (Mo, Day, Year)

4. Age

5. Postal (ZIP) Code

QUALIFIER

6. Telephone No. (Indicate Area Code)

(House No, Street, Municipality, Province)
7. Address:
8. Religion

12.Weight: ( kg )
15. Color of Eyes

18. Date entered service

9. Civil Status (Check box)
Single
Widower
Married
Separated
13. Height (cm)
16. Color of Hair
19. Date Retired

10. Citizenship

11. Sex (Check box)
Male
Female

14. Blood Type

17. Other Identifying Marks
20. Mode of retirement (Check box)
Compulsory Retirement
TPPD
Optional Retirement
Others (specify)

___________

21. Retirement Authority (General Orders No. and Date): ________________________________________________
24. How do you receive your pension? (Check Box)
23. If yes, how much is
22. Are you receiving monthly
Local Pick-up
RFSO
Authorized Rep
the present amount?
pension?
Thru Banks (indicate name of bank)__________
P__________________
Yes
No
___________________________________________
25. If yes, since when? ___________
26. Have you allotted part of your pension to another?
Yes
No
If yes, state the name of the allottee/ guardian/ common-law-wife and reason for allotment
(Last Name, First Name, Middle Name, Qualifier)
Address
Relationship
Reason

27. Person to be notified in case of emergency:

Name

Relationship

28. Are you also receiving pension from: GSIS
Yes
No
NAPOLCOM
Yes
No
AFP
Yes
No
Others ____________________________
BENEFICIARY/IES DATA (order of precedence)
I. Spouse legally married to the retiree while still in the service; legitimate, legitimated, legally adopted, illegitimate children
born while in the active service
II. Parents
29. Names of beneficiaries
Address
Date of
Civil
Relationship
(Last Name, First Name, Middle Name, Qualifier)
Birth
Status

I certify that the information herein are true and correct to the best of my knowledge. I have affixed my signature
and/or thumbmark to attest to its truthfulness and correctness; thereby, I may be held liable for prosecution on any
misrepresentation hereof.
Left
Right

Signature of Pensioner
DO NOT FILL-UP THE BOX BELOW:
Verified By:
__________________________
Records Section
Processed By:
___________________________
ID Section In-Charge

Reviewed By:
NUP VICTORIA T DE CASTRO
Chief ID Section, PRBS

Recommended By:
ROSALYN B CABRIGAS
Police Chief Inspector
Chief, Pension & Gratuity Div

Date Signed
Approved By:
 
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