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Form ADM 4-A

E-Form 1
LHF 01/18/10

PRIVATE EDUCATION RETIREMENT ANNUITY ASSOCIATON (PERAA)


16/F Multinational Bancorporation Centre
6805 Ayala Avenue, Salcedo Village, City of Makati
Tel. No. (02) 817-45-31 * Fax No. (02) 818-79-21 * E-mail: peraa@peraa.org
Website: http:// www.peraa.org

IMPORTANT: PLEASE READ CHECKLIST OF REQUIREMENTS & INSTRUCTIONS AT THE BACK


APPLICATION FOR

RETIREMENT
BENEFITS

DISABILITY
BENEFITS

DEATH
BENEFITS

NAME OF MEMBER __________________________________________________________________________ PERAA ID NO._______________


Last Name

First Name

Middle Name

MAILING ADDRESS __________________________________________________________________ CONTACT NO. ______________________


DATE OF BIRTH __________________ AGE ______ EFFECTIVITY DATE OF RESIGNATION ______________ TIN #: ____________________
LAST MONTHLY DEDUCTION FOR MULTI-PURPOSE LOAN (MPL), if any _______________________________________________________
NAME AND ADDRESS OF PARTICIPATING INSTITUTION(S) (From most recent)

PERIOD OF EMPLOYMENT

1. ____________________________________________________________________________________________

___________________________________

2. ____________________________________________________________________________________________

___________________________________

NAME AND ADDRESS OF NEW EMPLOYER, if any ____________________________________________________________________________

MONTH OF LAST CONTRIBUTION __________

BENEFIT CHECK TO BE:

MAILED

CLAIMED AT PERAA

FOR RETIREMENT BENEFITS ONLY: Date of Retirement: _______________________________

FOR DISABILITY BENEFITS ONLY: Date of Total Permanent Disability: _____________________


FOR DEATH BENEFITS ONLY: Date of Death of Member: ____________________________________________________________________________
APPLICANT'S FULL NAME (designated Beneficiary) ___________________________________________________________________________________
RELATIONSHIP TO MEMBER _____________________________________________________________________________________________________
MAILING ADDRESS______________________________________________________________________________________________________________

BY:

CERTIFIED CORRECT BY:

Name and Signature of Applicant


________________________
Date

CLAIM STUB for


Retirement Benefits
Name of Member: ________________________________________
Address: ________________________________________________
Employer: _______________________________________________

Name and Signature of School's Authorized Signatory


________________________
Designation

Disability Benefits

_______________________
Date

Death Benefits

Claim Received by: ____________________________________________


Date Received: ________________________________________________
Follow up on or after: ___________________________________________
For inquiries, pls. call: Tel # (02) 817-45-31 email address: memberservices@peraa.org

IMPORTANT: To claim check, please present 2 valid identification cards (e.g., school ID, PRC license, Driver's license, SSS ID, BIR ID, etc).

CHECKLIST OF REQUIREMENTS
ADM 4-A
Certificate of Employment with inclusive dates (indicating the first and last day of service with the school).
Certification from the school that the employee/member is officially retired from the school**.
Photocopy of Birth Certificate issued by the Local Civil Registrar or Baptismal Certificate. In the absence of these documents,
please submit a certification from the Office of the Civil Registrar General or the Local Civil Registry
Office that no records are available AND an Affidavit of Birth attested by two disinterested persons.*
Notarized Release and Quitclaim Form* (sample form attached).
Photocopy of any two (2) valid ID cards (e.g. School ID, PRC license, SSS ID, BIR ID, Driver's license) with picture and clear
signature. The photocopy should also be signed by the claimant.
Multi Purpose Loan (MPL) certificate of loan payment
Photocopy of approved SSS Disability Claim
Physician's Certification of PERMANENT TOTAL DISABILITY (PTD)
School's acceptance letter of the Physician's Certification of PTD of member
Special Power of Attorney if business is to be transacted by a representative, together with two (2) valid Identification Cards (with
picture and signature) of the member and representative.
Others _______________________________________________________________________________________
_______________________________________________________________________________________
Note: Blue form and Certificate of Employment should be signed by the authorized signatory of the school.
* Notarized by a Notary Public only.
** Requirement in availing tax exemption of benefits under RA 4917

INSTRUCTIONS
1. Submit only one copy of a complete application. Avoid erasures or alterations in your application and supporting
papers.
2. Fill out all applicable blanks and check all appropriate boxes. Print or type all entries.
3. Submit the complete form to your employer for signature of the school official/representative authorized to approve
benefit claims. ONLY the names and signatures of the school officials/representatives appearing on the Specimen Signature Card
submitted by the school will be honored.
4. Submit the complete form and other requirements as indicated above to PERAA.
Note: To claim your checks, please present the following:
1. At least 2 Identification Cards (e.g. laminated company ID, new SSS ID, new BIR ID, driver's license, PRC ID,
latest passport)
2. Special Power of Attorney in case a representative will claim the check & a photocopy of representative's ID cards.
3. Others _________________________________________________
_________________________________________________

REPUBLIC OF THE PHILIPPINES)


) S.S.
RELEASE AND QUIT CLAIM
KNOW ALL MEN BY THESE PRESENTS:
I, ______________________________________________, of legal age, Filipino and a resident of
_______________________________________________, for myself, my heirs, representative, successors and
assigns, do hereby RELEASE AND DISCHARGE, absolutely, irrevocably, wholly and fully the Board of Trustees of
PRIVATE EDUCATION RETIREMENT ANNUITY ASSOCIATION, its officers, from all actions, claims, demands,
and rights whatsoever pertinent to the kind of benefit I am claiming arising out and as a consequence of my membership
in the said Association.

WITNESS WHEREOF, I have hereunto set my hand this _____ day of ____________, 20___ at
______________________, Philippines.
___________________________________
Printed Name and Signature of Affiant

SIGNED IN THE PRESENCE OF


________________________________
Printed Name and Signature

_______________________________
Printed Name and Signature

BEFORE ME, a Notary Public for and in ___________________, personally appeared


________________________ with Residence Certificate No. __________ issued at ___________________ on
____________, 20____, known to me to be the same person who executed the foregoing instrument and he
acknowledged to me that the same is his free and voluntary act and deed.
WITNESS MY HAND AND SEAL on this ______ day of _____, 20__, at _____________________,
Philippines.
NOTARY PUBLIC
Until ___________
T.I.N. ___________
PTR # ___________
Issued at ___________
Issued on ___________
Doc. No. __________ Page No.
__________ Book No.
__________
Series __________

This document shall be valid only upon receipt of my PERAA check payment.
ACT'L 01/06
E Form