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APPLICATION FOR RETIREMENT/

SEPARATION/ LIFE INSURANCE BENEFITS
GSIS Form No. 06302017-RET

INSTRUCTIONS: Ensure that the application form is properly filled out and submit duly accomplished application form to the
nearest GSIS Office.
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, civil and/or criminal action.

Date:

I hereby apply for a retirement/separation/life insurance benefit with the GSIS and declare to the best of my knowledge
the following:

Last Name First Name Middle Name GSIS Business Partner (BP) No.
M I Glf-A EL CttAV E2.
Complete Mailing Address
AN 1LlN6 MLNOE2 CilVW
Date of Birth (mm/dd/yyyy) Place of Birth Gender Female PI Male
d7 I~~Iq~?~ MLN0L2 GIVIrE
Contact No. (Landline) Cellphone No. E-mail address

Civil Status ■ Married Single If married, Name of Spouse: (Last Name, First Name, Middle Name)
Separated Widow/Widower
Date of Marriage:
Retirement/Separation Benefits Previously Availed (if a licable)
RA 660 RA 1616 PD 1146 ■ RA 8291

I have the honor to apply for

Retirement benefits under the retirement mode marked below, effective . I affix my signature
beside my chosen option. (Please refer to the Terms and Conditions of each retirement mode on subsequent pages)
RETIREMENT RETIREMENT OPTIONS SIGNATURE
RA 660 ■ Below age 60, monthly annuity payable annually for 5 years
Aged 60 to below 63, 3-year lump sum, 2 years balance payable on the 63id Birthday;
monthly annuity after the S -year guaranteed period
Aged 63 and above, 5-year lump sum, monthly annuity after the 5-year guaranteed period
PD 1146 Immediate Monthly Pension
60 months x Basic Monthly Pension (BMP) and BMP after 5 years

RA 8291 Option 1: 60 months x BMP and BMP after 5 years

Option 2: 18 months x BMP and BMP to start on date of retirement
RA 1616 Refund of Retirement Premiums (Retirement gratuity to be paid by last Employer)
APPLICATION If you opt to retire under a retirement scheme with an immediate monthly pension, you may settle your
FOR CLASP outstanding loan obligation on installment basis under the Choice of Loon Amortization Schedule for Pensioners
(CLASP) program. The remaining balance of your outstanding obligation shall be restructured as a loan with an
interest rate of 10% per annum compounded annually (paco). Please indicate your choices below:

As payment for my outstanding obligation, please deduct from the proceeds of my retirement benefit the
amount equivalent to: SIGNATURE

100%, since I am not availing the CLASP

75%, remaining balance of 25% shall be paid through CLASP
50%, remaining balance of 50% shall be paid through CLASP
25%, remaining balance of 75% shall be paid through CLASP

Preferred repayment term for the remaining balance:

■ 1 year
■ 2 years
■ 3 years
I confirm that / have read and fully understood the PENSIONER RESTRUCTURED LOAN (PRL) Terms and Conditions and
undertake to comply with them. Pursuant to Republic Act (R.A.) No. 9510, otherwise known as the "Credit Information System
Act", and its Implementing Rules and Regulations (!RR), I hereby acknowledge and consent to: 1) the regular submission and
disclosure of my basic credit data and updates thereon to the Credit Information Corporation (CIC); and 1) the sharing of my
basic credit data with lenders authorized by the CIC, and credit reporting agencies and outsource entities duly accredited by
the CIC, subject to the provisions of R.A. No. 9510, its IRR and other relevant laws and regulations.
 TERMS AND CONDITIONS
1. RETIREMENT
A. Eligibility Requirements
1. Member shall be entitled to the retirement benefit, provided Member is separated from the service at the time of
application, and on condition that:

Under RA 660 1. Member has been in the service on or before May 31, 1977;
2. Member must be on permanent status at the time of retirement with continuous service for the last three (3)
prior to retirement and has made contributions for at least five (5) years; and
3. Member has met the age and service requirements (YOS) as indicated below:
Age 52 53 54 55 56 57 58 59 60 61 62 63 64 65 )
YOS 35 34 33 32 31 30 28 26 24 22 20 18 16 15
Under PD 1146 1. Member should have been separated/retired on or before June 23, 1997; and
2. Member has rendered at least fifteen (15) years of service in the government.

Under RA 8291 1. Member should have been separated/retired on or after June 24, 1997;
2. Member has rendered at least fifteen (15) years of service in the government;
3. Member is at least sixty (60) years of age at the time of retirement;
4. Member is not receiving a monthly pension benefit due to permanent total disability; and
5. Member must not be a uniformed personnel of PNP, BJMP and BFP.

Under RA 1616 1. Member has been in the service on or before May 31, 1977;
2. Member, regardless of age, must have at least twenty (20) years of service in the government at the time of
retirement; and
3. Member must have rendered continuous service for the last three 13) years and must not incur leave without
pay of more than one (11 year except in cases of death, disability, abolition or phase-out of position due to
reorganization. Except for teachers who are allowed more than one (1) year leave without pay under the
Magna Carta for Teachers.

2. Request for conversion from one mode of retirement to another shall not be allowed.
3. The retirement proceeds shall at all times be subject to deduction for any outstanding indebtedness the member
may have incurred with GSIS, pursuant to Articles 1231 and 1178 of the Civil Code, GSIS Laws (RA 660, PD 1146, RA
1616, RA 8291 and PD 1146) and existing policies.
B. Conditions For Receipt Of Monthly Pension
Upon reaching the age 60, or after the end of the S-year guaranteed period, the qualified pensioner is required to
personally appear at GSIS Office nearest his/her place of residence. Member shall be required to fill up a request for
commencement of pension and afterwards enroll for the GSIS UMID-Compliant eCard/Kiosk transaction card.
Previously registered old-age and survivorship pensioners shall no longer be required to comply with the Annual
Renewal of Active Status (ARAS) EXCEPT. 1) Pensioners on suspended status as of April 30, 2011 and has not renewed
active status as of present date; and 2) Pensioners whose birth month falls in CV 2011 on the months of February,
March or April. The pensioners living abroad or in the ARMM Region shall be required to comply with the ARAS on
their birth month every year.

II. SEPARATION
A. Entitlement To Separation Benefits Under RA 8291
A member who has accumulated a minimum of three (3) years creditable service shall be entitled to separation benefit upon
resignation or separation under the following terms:
1. For member with at least three (3) years but less than fifteen (15):
A cash payment equivalent to one hundred percent (100%) of the average monthly compensation for every year of creditable
service the member has paid contributions, but not less than Twelve Thousand Pesos (P12,000.00), payable upon reaching sixty
years of age or upon separation, whichever comes later.
2. For member with at least fifteen (15) years of service and less than sixty (60) years of age upon separation:
a. A cash payment equivalent to eighteen (18) times the basic monthly pension, payable at the time of resignation or
separation;
b. An old-age pension benefit equal to the basic monthly pension, payable monthly for life upon reaching age 60.
B. Prescriptive Period For Filing Of Separation Benefit
Application for separation benefits must be filed within four (4) years from the date of separation as provided for under RA 8291.

III. COMPULSORY LIFE INSURANCE BENEFITS UNDER THE LIFE ENDOWMENT POLICY (LEP)
A member under this policy may be entitled to any of the following benefits, depending on the circumstances:
1. Maturity benefit The face amount payable to the member upon maturity of the policy.
2. Cash Surrender Value The earned values during the term of the insurance payable to the member when he is separated
from the service before maturity date of the policy or when he is considered as a case of
Permanent Total Disability (PTD).
3. Death Benefit The face value of the policy payable to designated beneficiary/beneficiaries or legal heirs, in the
absence of the former, upon the death of the member.
4. Accidental Death Benefit An additional benefit equivalent to the amount of Death Benefit when the member dies by
accident. In this connection, proof must be presented to sufficiently establish that the cause of
the member's death is accidental. The right to present sufficient proof to show that death was
accidental shall prescribe if the claim for ADB is filed four (4) years after the death of the
member.
5. Cash Dividend A policyholder is entitled to dividends subject to the guidelines as approved by the GSIS Board.
This is not a guaranteed benefit.