APPLICATION FOR BENEFIT CLAIMS

TO: COMMANDING GENERAL, PAF

Col Jesus Villamor Air Base, Pasay City
Metro Manila

FR:

I hereby apply for the following benefits intended to me as legal heirs/beneficiary/ies of the
late __________________________.

( ) Reimbursement of burial PD 1496 ( ) Comm of Lv/Furl-RA 611

( ) Death Gratuity ( ) Posth/Sep Pen-PD 1638
( ) Educational Benefit PD 577

Hereunder is the data/info sheet of my husband/son.

LAST NAME: _____________ FIRST NAME: _____________ MIDDLE NAME: ____________
RANK: _________ AFSN: _________ BR OF SVC: _________ CIVIL STATUS: ___________
BIRTH DATE: ____________ PLACE OF BIRTH: _____________________________________
CAUSE OF DEATH: _____________________________________________________________
TYPE OF DEATH: ( ) BATTLE ( ) NON BATTLE
DATE ENTERED MIL SVC: ________________ LENGTH OF SVC: _______________________
TOTAL LEAVE/FURLOUGH BALANCE: _____________________________________________
NAME OF SPOUSE/PARENTS: ____________________________________________________

BENEFICIARIES
FIRST NAME MI LAST NAME BIRTHDATE AGE RELATIONSHIP
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________________________________
I hereby certify the correctness of the above information.

________________________
NAME AND SIGNATURE