NAME :

POSITION :

REASON :
OFFICE :
EFFECTIVITY :

Requirements Signature/Date Received

Application for Terminal Leave Benefits
Clearance from money, property, legal accountablity from
the Central Office
Clearance from money, property, legal accountablity from
the Regional Office, if applicable
Request for Service Record (bit.ly/HRDSonline)

Authority to Deduct Accountabilities from TLB

Statement of Assets, Liabilities and Net Worth (SALN)
*duly notarized
Affidavit that there are no pending criminal investigation or
prosecution against the applicant *duly notarized

Landbank of the Philippines Savings Account

For HRDS - Central Office

Obligation Request for Terminal Leave Benefits

Disbursement Voucher of Terminal Leave Benefits

Certified photocopy of leave cards as of last date of service
duly reviewed by HRDS-PAD .
Computation of Accumulated Leave Credits issued by
HRDS-PAD
Computation of Terminal Leave Benefits
 Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Intramuros, Manila
HRDS-PAD Form No. 04
(Revised, January 2015)
APPLICATION FOR TERMINAL LEAVE
(Instructions and Documentary Requirements at the back)

DATE OF FILING OF APPLICATION: __________________________________________

MEMBER’S INFORMATION:
Last Name First Name Middle Name

Position: Salary (Monthly) LBP Account Number

Complete Residential Mailing Address:

Contact No. (Residential Landline) Cellphone No. E-mail address

Reason for Terminal Leave Benefit Compulsory Transfer to

Optional Retirement Resignation
Claims (Mark box with a “”) Retirement Another Office

NAME OF CLAIMANT IF MEMBER IS DECEASED:

Last Name First Name Middle Name

Complete Mailing Address

Contact No. (Residential Landline) Cellphone No. Relation to the Deceased Member

Witnesses to thumbmark:

1. ___________________________________________

2. __________________________________________
Signature of Applicant/Claimant Right Thumbmark
over Printed Name (if unable to affix signature)

TO BE FILLED UP BY HRDS/IMSD

CERTIFICATION OF LEAVE CREDITS Based on HRDS’ evaluation of the submitted leave journals, the total leave
credits as of _______________________are as follows:
as of ______________________________.
Vacation Leave: ____________
VACATION SICK TOTAL
Sick Leave: ____________
____________
TOTAL: ____________

Days Days Days

CERTIFIED CORRECT:

PROCESSED BY:

___________________ _________ ________________________ ______________

Personnel Officer Date Administrative Officer Date
APPROVED:
 INSTRUCTIONS:

Ensure that the application form is properly filled out and documentary requirements are
complete

DOCUMENTARY REQUIREMENTS

1. Clearance from money, property and legal accountability from the Central Office and from
Regional Office of last assignment;
2. Certified photocopy of leave card as at last date of service duly audited by the
HRDS/IMSD;
3. Certificate of Accumulated Leave Credits (CALC) issued by the HRDS/IMSD;
4. Updated Service Record indicating inclusive date of leave without pay issued by the
HRDS/IMSD;
5. Certification of Last Day of Actual Service issued by the HRDS/IMSD;
6. Updated Statement of Assets, Liabilities and Net Worth (SALN);
7. Certified photocopy of appointment/Notice of Salary Adjustment (NOSA) showing the
highest salary received if the salary under the last appointment is not the highest;
8. Computation of terminal leave benefits duly signed/certified by the accountant;
9. Applicant’s authorization (in affidavit form) to deduct all financial obligations;
10. Affidavit of applicant that there is no pending criminal investigation or prosecution
against him/her (RA No. 3019);
11. In case of resignation, employee’s letter of resignation duly accepted by the Head of the
Agency;
12. In case of transfer, employee’s Authority to Transfer and Certificate of Assumption to Duty;
13. Existing Land Bank of the Philippines (LBP) Account Number of Retiree/Claimant.

ADDITIONAL REQUIREMENTS IN CASE OF DEATH OF CLAIMANT

1. Death certificate authenticated by NSO;

2. Marriage contract authenticated by NSO;
3. Birth certificates of all surviving legal heirs authenticated by NSO;
4. Designation of next-of-kin;
5. Waiver of rights of children 18 years old and below;
6. Request letter to the Chief Accountant that the claims be paid in the form of cheque.

Application Received by: __________________________________________________

Date Received: __________________________________________________________

 CS Form No. 7 DOLE-QF-SP-01.01
Series of 2017 Revision No. 07
Effective Date: 01 March 2023
DEPARTMENT OF LABOR AND EMPLOYMENT
CLEARANCE FORM (For 1st and 2nd Level Positions)
(Instructions at the back)

I PURPOSE:

Date of Application
TO: DEPARTMENT OF LABOR AND EMPLOYMENT - CENTRAL OFFICE
I hereby apply for clearance from money, property and work-related accountabilities for:
Purpose:  Transfer  Resignation  Other Mode of Separation:
 Retirement  Leave Please specify: ____________________
Effectivity/Inclusive Period: ________________________

Office of Assignment: ____________________________

Position/SG/Step: Name and Signature of Employee

II CLEARANCE FROM WORK-RELATED ACCOUNTABILITIES

We hereby certify that this applicant is cleared of work-related accountabilities from this Unit/Division/Office/Dept.

_______________________________ _______________________________
Immediate Supervisor/Division Chief Head of Office
III CLEARANCE FROM MONEY AND PROPERTY ACCOUNTABILITIES
Cleared
Name of Unit/Office/Department Please settle the following Name of Clearing Officer/Official Signature
(Date)
1. Administrative Service
_________________________
Chief, Cash Division
a. Transaction, Processing & Billing Services
_________________________
b. Supply and Property Procurement and Director, Administrative Service
Management Services
2. Library
a. Library Services _________________________
Department Librarian
3. Financial and Management Service
_________________________
Chief Accountant
a. Financial Services
_________________________
Director, Financial and Management Service
4. Cooperative/Union/Provident Fund
_________________________
Chairperson, DOLEEC

_________________________
a. Agency-accredited Union/Cooperative Treasurer, DOLE-OEA

_________________________
Treasurer, DOLE-EU

_________________________
Treasurer, DOLEPFI, Inc.
b. DOLE Provident Fund (DOLEPFI), Inc.
_________________________
Chief Executive Officer
5. Human Resource Development Service
a. Human Resource Welfare & Assistance

b. Payroll & Remittance Services _________________________

Director, Human Resource Development Service

c. Scholarship Services
IV ADMINISTRATIVE CASE:
a. Office of the Assistant Secretary for Human Resource _________________________
(as to Administrative Case per AO 22, s. 2020 and Assistant Secretary for General Administration and
AO 22-A, s. 2020) Support to Operations Cluster

with pending administrative case

NO pending administrative case

V CERTIFICATION

______________________________________
Signature over Printed Name of Agency Head

Page 1 of 2
INSTRUCTIONS:

1. Employees who are retiring, being separated, transferring to other agencies,

leaving the Philippines and going on maternity leave of absence shall prepare
this form in quadruplicate.

2. This clearance should be duly accomplished before paying the last salary or
any money due the employees. (Specify which type of clearance: maternity
leave, retirement, transfer, etc.)

3. If the employees are cleared from a unit/office/department, the

clearing/authorized official may attach to this clearance the pertinent
document/s that shall prove that the employees are cleared of any obligation or
accountability from their office, if any, and tick the box under the "Cleared"
column before affixing their signatures.

4. If the employees appear to have uncleared accountability/ies from a

unit/office/department, the clearing/authorized official shall attach to this
clearance the pertinent document/s that shall prove that the employees have
remaining obligation or accountability from their office further indicating the
necessary action/s that the employee must satisfy in order to be cleared, and
tick the box under the "Uncleared" column. The clearing/authorized official
must only sign this clearance corresponding to their name once the employee
have complied the necessary requirements and cleared of all the obligation/s
and accountability/ies from their office. They must also tick the box under the
"Cleared" column.
5. The HRMO shall distribute copies of approved clearance as follows: original to
the employee; duplicate to be attached to the payroll or voucher; triplicate to
human resource unit file; and fourth copy to accounting/auditing office.

6. Processing of clearance certificate shall follow the order of number indicated.

Page 2 of 2
 PRepublic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Intramuros, Manila

HRDS-PAD Form No. 05

(Revised, January 2015)

FOR : The Directors

Financial and Management Service
Human Resource Development Service

SUBJECT : Authority to Deduct Accountabilities from Terminal Leave Benefits

In connection with my application for Department Clearance due to ___________________________

effective ___________________________, I hereby authorize the Department to deduct my outstanding
accountabilities listed below from my terminal leave benefits:

Unliquidated Cash Advance P _________________________________

Disallowance/s:

_________________________________ _________________________________
_________________________________ _________________________________

Loan/Credit Obligations _________________________________

Others:
_________________________________ _________________________________

_________________________________ _________________________________

_________________________________ _________________________________

TOTAL P ________________________________

__________________________________________
(Signature over printed name)

__________________________________________
(Date)
 Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Intramuros, Manila

AFFIDAVIT

I, __________________________ of legal age, Filipino and a resident of

__________________________________ after having been sworn to in accordance
with law, depose and say:

1. That I am a holder of a _____________ position at the

______________________________.

2. That there is no criminal case filed/pending against me in court,

either in the personal or official capacity.

3. That I am executing this affidavit to support my claim for benefits

by virtue of my _______________ effective ________________.

__________________________
AFFIANT

CTC No. _____________________

Issued on_____________________
Issued at _____________________

OATH

SUBCRIBED AND SWORN to before me this _____ day of __________

______, in the City of Manila, Philippines.

_______________________________
Administering Officer