ASSOCIATED PHILIPPINE SEAFARERS! UNION ITF ttigtca Roxd comer Mahara Steet, Diiman, Quezon ty 103, Pitpines et (00) 00 Fog 90922 103, 1:99 Fas (32) MBGN2MO ra &) INDORSEMENT pate:26 JAN! 202) 2020 To: Finance Department Re: CLAIM FOR RETIREMENT/PROVIDENT (TCC) [fame ot wember trai Adare JIMMY _T NUEVA JR. aoayneuevaGaniail.cor Rankivesser Proven Pasibook Wo | Te eel Nurber: [ovefindon oP fe) Ce_[ MT HALCONTRADER| CANT el 33453 150 1D Wo JOate of ve Tota Amourtot Camm vo4e5o / APRN 23, 2018 (om isen NEE For bank depos, please specify bank details (D8PI OBO /0 Peso Dollar Account only): 71 ‘Account Name: LIMMY_ T: NUEVA JR. Account Number: 2484340162 ank:_ BP ranch: _1KAUS For money transfer transaction, please specify the following detalls (Palawan Express only} Name of Receiver adsress Destination Branch: Contact Number: Attachments: certificate of Employment O Passport 1D Doctors Certificate In case cf iness/sabity) Dseaman's Book {DrPsuib orany valid ID with signature) Death Certificate (Incase death of member) Piseae Spch PSU may deem necessary); thisis to cert that the information | provided in ths frm are tre and accurate tothe best of my knowles! se ive my consent tothe Associated Philippine Seafarers’ Union (PSU) to use the information above ia order to process the withdrawal of my provident fund contribution. guy, rw JiRiay T_ NUEVA SR 25 JAN 7021 Date Signature over Printed Name Documents Checked/Verified By: (Mo be fled out by #5u Offce) Scanned with CamScannerScanned with CamScanner