Date:
Month Day Year
Date
Personal Submission
Personal Submission emai Submission
Old Age Pension
Old Age Pension Guardian
Name
First Name Middle Name Last Name
Residential Address (House No., Street, Barangay, City/Municipality, Province and Zip Code)
GSIS Business Partner (BP) No.
Name of Agency/Office
Date of Retirement
Month Day Year
Date
Date of Birth (mm/dd/yyyy)
Month Day Year
Date
Place of Birth
Gender
Civil Status (Indicate if Married, Single, Widow/Widower or Annulled)
Contact No. (Landline)
Mobile Phone No.
E mail address
example@example.com
If married, Name of Spouse (Last Name, First Name, Middle Name)
Date of Marriage:
Month Day Year
Date
PD 1146
PD 1146 RA 8291 RA 7699
Viber Video Call through mobile number (please provide country code):
Viber Video Call through mobile number (please provide country code):
Facebook Messenger with username:
Skype Video call with Skype address:
Skype Video call with Skype address:
Date of Birth of Deceased (mm/dd/yyyy)
Month Day Year
Date
Relation to Deceased Member
Date of Death (mm/dd/yyyy)
Month Day Year
Date
Date of Retirement of Deceased Member
Month Day Year
Date
Name and Address of Agency of the Deceased Member
Civil Status at the time of Death
Signature of Applicant
Clear
Thumb mark (if unable to affix signature)
Clear
1.
2.
Should be Empty: