Application Form for PAF MRS Claims

Reference Nr. __________ Date of Application: ________________

(to be filled out by OAFA personnel)

Section A. Information about the Spouse/Applicant

1. Full name (last, first, middle) 2. Relationship to deceased:

3. Date of birth (mm/dd/yyyy) 4. Gender: 5. Age:

6. Address: 7. Contact Number:

Section B. Information About the Deceased

1. Full name (last, first, middle) 2. Rank/AFP Serial Number/BOS:

3. Date of birth (mm/dd/yyyy) 4. Date of death (mm/dd/yyyy) 5. Cause of death:

6. Last Unit assignment: 7. Status of Member upon Death:

 Active
 Retired
8. Address:

Please check the following requirements submitted and attach to this form:

 Death Certificate  Latest Payslip (if active)

 PAF MRS Certificate of Lifetime Membership (only  Report of Death from Unit (if active)
for those with lifetime membership)
 Marriage Contract  Special Power of Attorney (if applying on
behalf of the claimant)
 Burial Receipt
 Photocopy of 2 government issued IDs of Spouse
If spouse of the member is also deceased and other declared beneficiary/ies will claim, provide also the
following:

 Death Certificate of Spouse of Member

 Birth Certificate of Claimant
 Marriage Contract of Claimant (for married female claimants)
 Waiver of Rights of other beneficiaries (duly notarized)

*Note: All documents must be original/authenticated copies.

I certify that the above information is true and correct.

________________________________________
SIGNATURE OVER PRINTED NAME OF APPLICANT

Received by:
_______________________________
SIGNATURE OVER PRINTED NAME