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03122014-CARF Check Alteration and Replacement Form (CARF)
GSIS form for alteration and replacement of check
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: F ORM N O . 03122014-CARF
CHECK ALTERATION AND REPLACEMENT FORM (CARF)
(Please read instructions below)
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 and/or criminal action.
GSIS ID No./Policy No./Pensioner’s ID No.
Member
Pensioner
Others ____________________________________
Payee of Check to be Replaced: ________________________________________________________
If survivor/beneficiary is filing request, indicate full name (First Name, Middle Initial and Surname)
Telephone No. (Landline)
Cellphone No.
_________________________________________________________________________________________
Residential Address of Applicant
E-mail Address
Agency Name/Address (if active member)
Check Particulars
Reason for Replacement
Retirement
Life Claim
Lost/Stolen
Dividend
Type of Check:
Others _________________________________________
Stale
Check No. ___________________________
Check Date _______________________________
Erroneous Name
Check Amount _______________________
Drawee Bank _____________________________
Others
______________________________________________________________
______________________________
Signature of Applicant over Printed Name
Date Filed
DOCUMENTARY REQUIREMENTS
FOR CHECK RELEASED TO PAYEE
a. Lost
1) Check Alteration and Replacement Form (CARF);
2) Affidavit of Loss
b. Damaged
1) Check Alteration and Replacement Form (CARF);
2) Physical Check
3) UMID, eCard or ay two (2) prescribed GSIS valid IDs
of claimant/s
c. Deceased Payee
1) Check Alteration and Replacement Form (CARF);
2) Physical check
3) NSO Death Certificate if no claim for funeral benefit has
been filed;
4) Notarized Proof of Surviving Legal Heirs if no claim for
survivorship benefit has been filed;
5) NSO Birth and Marriage Certificate of Legal Heirs (for
spouse and married female heirs);
6) UMID, eCard or any two (2) prescribed GSIS valid IDs of
claimant/s; and
7) Notarized deed of extra judicial settlement designating
one payee.
d. Wrong Payee Name
1) Check Alteration and Replacement Form (CARF);
2) Physical Check;
3) NSO Birth Certificate of the Payee; and
4) UMID, eCARD of any two (2) prescribed GSIS valid
IDs of claimant/s
e. Stale Check
1) Check Alteration and Replacement Form (CARF);
2) Physical check
FOR CHECK WITH GSIS
a. Lost
1) Check Alteration and Replacement Form (CARF);
2) Notarized Incident Report prepared by the
concerned personnel with the custody of the check,
duly noted by the DC, Officer I or Extension Head,
whichever is applicable
b. Damaged
1) Physical Check
c. Deceased Payee
1) Check Alteration and Replacement Form (CARF);
2) Physical Check
3) NSO Death Certificate if no claim for funeral benefit has been
filed;
4) Notarized proof of Surviving Legal Heirs if no claim for
survivorship benefit has been filed;
5) NSO Birth and marriage Certificate of Legal Heirs (for spouse
and married females heirs); and
6) UMID, eCard or any two (s) prescribed GSIS valid IDs of
claimant/s;
d. Wrong Payee Name
1) Check Alteration and Replacement Form (CARF);
2) Physical Check;
3) NSO Birth Certificate of the Payee; and
4) UMID, eCARD of any two (2) prescribed GSIS valid IDs
of claimant/s
e. Stale Check
1) Check Alteration and Replacement Form (CARF); and
2) Physical check
