Form No.

A-SURV-06-10
APPLICATION FOR SURVIVORSHIP BENEFITS
(Please read instructions at the ac!"
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.
Date of Filing of Application:
!"ust be filed #ith $%&% #ithin four !'( years from the Date of Death of Deceased "ember(
For the information of the %ystem, & hereby declare to the best of my kno#ledge the follo#ing
A# DECEASED MEMBER
)A"*
+ast )ame First )ame "iddle )ame
,-+&./ )-: $%&% &D )-:
)A"* 0 ADD1*%% -F +A%2 $-3*1)"*)2 -FF&.*
DA2* -F D*A24: .&3&+ %2A25%
D*A24 .*12&F&.A2* A22A.4*D: 6 7 /*% 6 7 )-
If none, state and attach other evidence of death: ___________________________________
%2A25% -F *",+-/"*)2 A2 24* 2&"* -F D*A24 !check applicable status(:
6 7 ,*)%&-)*1 6 7 %*,A1A2*D 6 7 A.2&3* %*13&.*
&F ,*)%&-)*1/%*,A1A2*D, DA2* -F 1*2&1*"*)2/%*,A1A2&-):
B# SURVIVING HEIRS
,1&"A1/ 8*)*F&.&A1&*%
I. Surviving Spouse:
)ame: Date of 8irth
+ast First "iddle
"ailing Address:
A22A.4*D D-.5"*)2%:
6 7 "arriage .ertificate .ertified by )%-
6 7 2#o valid &Ds #ith picture of spouse !Driver9s license, ,assport, %%%/$%&% &D, -ffice &D(
6 7 Affidavit of %urviving %pouse stating under oath that he/she is the surviving spouse of deceased member/pensioner,
that he/she #as dependent for support upon the deceased member/pensioner and that he/she is unmarried at the time
of application for survivorship
II. Surviving Dependent Children:
)A"* 8&124 DA2* ADD1*%%
A22A.4*D D-.5"*)2%:
6 7 8irth .ertificate .ertified by )%- of all dependent children listed above
6 7 &f guardian is not the parent of dependent children, a +etter of $uardianship issued by the court
6 7 Affidavit of $uardianship by the guardian stating that he/she is the legal guardian of the above listed dependent
children, that all of them are unmarried, not gainfully employed, not over the age of majority, or if over the age of
majority, is incapacitated and incapable of self:support due to a mental or physical defect ac;uired prior to the age
of majority
6 7 2#o valid &Ds of $uardian !Driver9s license, ,assport, %%%/$%&% &D, -ffice &D(
6 7 &f Dependent .hild is more than age of majority, Doctor9s .ertificate certifying under oath that the dependent
child is incapable of self support due to mental or physical defect ac;uired before reaching the age of majority
(Please see back portion for continuation of the application form and signature of applicant
%*.-)DA1/ 8*)*F&.&A1&*% !&n the absence of ,rimary 8eneficiaries(
I. Surviving Parents
)ame of Father: Date of 8irth
+ast First "iddle
"ailing Address:
)ame of "other: Date of 8irth
+ast First "iddle
"ailing Address:
A22A.4*D D-.5"*)2%:
6 7 2#o valid &Ds #ith picture of parent9s !Driver9s license, ,assport, %%%/$%&% &D, -ffice &D(
6 7 Affidavit of %urviving parents stating under oath that the deceased member/pensioner at the time of death #as not
survived by a spouse or dependent children and that they #ere dependent for support from the said deceased
member/pensioner
6 7 8irth .ertificate of Deceased member/pensioner certified by )%-

II Surviving Dependent !randchildren
)A"* 8&124 DA2* ADD1*%%
A22A.4*D D-.5"*)2%:
6 7 8irth .ertificate .ertified by )%- of all dependent grandchildren listed above
6 7 8irth .ertificate of the parents of the dependent grandchildren sho#ing that the said parents #ere the legitimate
children of the deceased member/pensioner certified by )%-
6 7 &f guardian is not the parent of dependent grandchildren, a letter of guardianship issued by the court
6 7 Affidavit of $uardianship by the guardian stating that he/she is the legal guardian of the above listed dependent
grandchildren, that they are all the legitimate grandchildren of the deceased member/pensioner, that all of them are
unmarried, not gainfully employed, not over the age of majority, or if over the age of majority, is incapacitated and
incapable of self:support due to a mental or physical defect ac;uired prior to the age of majority, and that the
deceased member is not survived by a spouse or dependent children
6 7 2#o valid &Ds of $uardian !Driver9s license, ,assport, %%%/$%&% &D, -ffice &D(
6 7 &f Dependent grandchildren is more than age of majority, Doctor9s .ertificate certifying under oath that the
dependent child is incapable of self support due to mental or physical defect ac;uired before reaching the age of
majority
III Surviving "egal #eirs b$ Intestate Succession (In the absence of primar$ or secondar$ beneficiar$ heirs
)A"* 1*+A2&-)%4&, ADD1*%%
A22A.4*D D-.5"*)2%:
6 7 8irth .ertificate of Deceased member/pensioner certified by )%-
6 7 8irth .ertificate of legal heirs certified by )%-
6 7 "arriage .ertificate of the independent spouse certified by )%-
6 7 Deed of *<tra:judicial settlement of legal heirs of deceased member/pensioner
6 7 ,roof of ,ublication of the Deed of *<tra:=udicial %ettlement in a ne#spaper of general circulation
CERTIFICATION
I hereb$ certif$ that the foregoing information are true and correct and the attached documents are authentic.
Upon filing of this application, it is n!"#stoo! that I ha$" p#"$iosl% s"c#"! a t"ntati$" co&ptation of
th" a&ont of '"n"fits I (ill #"c"i$", incl!ing th" a&onts !"!ct"! th"#"f#o& in pa%&"nt of &%
npai! o'ligations (ith GSIS an! I fll% confo#& to th" sa&")
________________________________
Signature of %pplicant&'epresentative
over Printed (ame
Date 2el > / .ell ,hone )o. of .laimant
TO BE FI**ED U+ B, +ERSONNE* OFFICER
2he undersigned hereby certifies that the late ", #as an employee of
this office, and further certify that the claimant/applicant has not filed #ith this office any claim for $ratuity 8enefits
pursuant to 1A ?@?@ #ith this -ffice..

%ignature of ,ersonnel -fficer over )ame of Agency Date
,rinted )ame