HQP-PFF-285

APPLICATION FOR (V04, 10/2019)

PROVIDENT BENEFITS (APB) CLAIM CLAIM FILE No.

(To be filled out by member/claimant. Print this form back to back on one single sheet of paper)
TYPE OR PRINT ENTRIES
MEMBERSHIP PROGRAM  Pag-IBIG I  MODIFIED Pag-IBIG II (MP2)
REASON FOR CLAIM (Check appropriate box)
 MEMBERSHIP TERM MATURITY  TERMINATION FROM SERVICE BY REASON OF HEALTH  PERMANENT DEPARTURE FROM THE
 RETIREMENT  CRITICAL ILLNESS OF THE MEMBER OR ANY OF HIS COUNTRY
Effective Date of Retirement_____________ IMMEDIATE FAMILY MEMBER  DEATH
Last Day of Service ___________________  Member  Immediate Family Member Date of Death __________________
 PERMANENT TOTAL DISABILITY/ Please specify type of illness:_________________________________  EXPATRIATE
INSANITY  OPTIONAL WITHDRAWAL  MODIFIED Pag-IBIG II (MP2) MATURITY
MEMBER’S PERSONAL DETAILS
LAST NAME FIRST NAME NAME EXTENSION (e.g., Jr., II) MIDDLE NAME MAIDEN NAME
(For married women)

DATE OF BIRTH MARITAL STATUS Pag-IBIG MID No./RTN

 Single/Unmarried  Widow/er  Annulled
 Married  Legally Separated
CLAIMANT, if other than the Member (Last Name, First Name, Name Extension, Middle Name) RELATIONSHIP TO MEMBER

ADDRESS AND CONTACT DETAILS

MEMBER’S PRESENT HOME ADDRESS MEMBER/CLAIMANT CONTACT DETAILS
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No. Street Name Subdivision COUNTRY + AREA CODE TELEPHONE
NUMBER
Barangay Municipality/City Province/State/Country (if abroad) ZIP Code Home

CLAIMANT’S PRESENT HOME ADDRESS (Leave blank if the same as member) Cell Phone (Required)
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No. Street Name Subdivision

Email Address
Barangay Municipality/City Province/State/Country (if abroad) ZIP Code

EMPLOYMENT DETAILS FROM DATE OF Pag-IBIG MEMBERSHIP (Use another sheet if necessary)
DATE OF Pag-IBIG MEMBERSHIP
EMPLOYER/BUSINESS NAME EMPLOYER/BUSINESS ADDRESS
FROM (Month/Year) TO (Month/Year)

AUTHORITY TO CREDIT AUTHORITY TO TRANSFER

IN THE EVENT OF THE APPROVAL OF MY APPLICATION FOR PROVIDENT BENEFITS IN THE EVENT OF THE APPROVAL OF MY APPLICATION FOR PROVIDENT
CLAIM, I HEREBY AUTHORIZE Pag-IBIG FUND TO CREDIT MY CLAIM PROCEEDS TO BENEFITS CLAIM, I HEREBY AUTHORIZED Pag-IBIG FUND TO TRANSFER MY
MY PAYROLL ACCOUNT/DISBURSEMENT CARD THAT I HAVE INDICATED BELOW: CLAIM PROCEEDS TO MY MP2 ACCOUNT THAT I HAVE INDICATED BELOW:
PAYROLL ACCOUNT/DISBURSEMENT CARD No. BANK’S ADDRESS MP2 ACCOUNT NO. AMOUNT TO BE TRANSFERRED

SIGNATURE OF MEMBER DATE SIGNATURE OF MEMBER DATE

APPLICATION AGREEMENT
I hereby certify that I have read and understood the contents hereof, including the guidelines and instructions indicated at THUMBMARKS OF MEMBER/CLAIMANT
the back portion of this form. I further certify under pain of perjury that all information I have indicated herein are true and (If unable to sign)
correct to the best of my knowledge and belief, and that my signature or thumbmark appearing herein is genuine and
authentic. I likewise understand that the processing of this application is subject to pertinent provisions of the implementing
rules and regulations of the Pag-IBIG Fund. In the event of any outstanding Pag-IBIG loan, Pag-IBIG Fund is hereby
authorized to withhold, in whole or in part, the provident benefit subject of this claim, and apply the same as payment to
the said loan as well as other obligations due to the Pag-IBIG Fund as of the date of this application.
I hereby waive my rights under R.A. No. 1405 and authorize Pag-IBIG Fund to verify/validate my payroll LEFT THUMB RIGHT THUMB
account/disbursement card number. (To be done in the presence of Pag-IBIG Fund Personnel)

_________________________________
MEMBER/CLAIMANT _______________________________ _____
(Signature over Printed Name) (Signature over Printed Name of Witness) Date

THIS PORTION IS FOR Pag-IBIG Fund USE ONLY

CLAIMS/HL/STL/LOYALTY CARD VERIFICATION
DV/CHECK/PN/ DATE FILED/HL AS
PARTICULARS WITH WITHOUT OUTSTANDING BALANCE VERIFIED BY DATE
APPLICATION/HL ID NO. TAKEOUT DATE OF
CLAIMS
HOUSING LOAN
MULTI-PURPOSE LOAN
CALAMITY LOAN
LOYALTY CARD
PAYEE/S (Use another sheet if necessary) REMARKS

RECEIPT OF APPLICATION
RECEIVED BY DATE REVIEWED BY DATE APPROVED BY DATE

DISAPPROVED BY DATE REMARKS

THIS FORM MAY BE REPRODUCED. NOT FOR SALE


GUIDELINES AND INSTRUCTIONS
A. When to File
The Application for Provident Benefits Claim (APB [HQP-PFF-285]) may be filed upon the occurrence
of any of the following:
1. Membership Maturity - shall be based on 20 years of membership with the Fund, reckoned from
the initial Pag-IBIG Fund Receipt (PFR) date; provided, the member has remitted a total of 240
monthly membership savings to the Fund at the time of maturity;
2. Retirement - a member shall be compulsorily retired under the Fund upon reaching the age of 65.
A member may opt to retire earlier under the Fund upon the occurrence of any of the following
events, provided the member is not a housing loan borrower:
a. Actual retirement from the SSS, GSIS, or from government service by provision of law;
b. Retirement under a private employer’s provident/retirement plan, provided that the member is
at least 45 years of age at the time of retirement;
c. Reaching the age of sixty (60).
3. Permanent Total Disability (PTD) or Insanity – PTD refers to the loss or impairment of a physical
or mental function resulting from injury or sickness, which incapacitates said member to perform
any work or engage in any business or occupation;
4. Critical illness of the member or any of his immediate family member, as certified by a licensed
physician, under any of the following categories:
a. Cancer
b. Organ Failure
c. Heart-related Illness
d. Stroke
e. Neuromuscular-related Illness
The immediate family member includes any of the following:
- Spouse
- Parent
- Children
- Sibling
- Grandparents
- Grandchildren
- Legally adopted children shall only be included insofar as applications for withdrawal of savings
of their adoptive mothers or adoptive fathers
5. Termination from Service by Reason of Health - a member can no longer render service to an
employer due to severe health conditions, as certified by his doctor;
6. Death;
7. Permanent Departure from the Country - a member has been permitted by his host country to
remain there indefinitely or has permanently left the Philippines to reside in another country;
8. Optional Withdrawal of Pag-IBIG Savings - members of the Fund after the effectivity of R.A. 9679
shall have the option to withdraw his or her TAV on the fifteenth (15 th) year of continuous
membership. Provided the said member has no outstanding loan with the Fund at the time of
withdrawal. This option may be exercised only once during the membership term;
9. Any other reasons as may be approved for by the Board.
B. Who May File
The application may be filed by the member, his guardian, or any authorized representative/s. If the
reason for claim is death of the member, the application may be filed by his heir/s or the latter’s
representative/s, or any appointed court administrator or executor.
HQP-PFF-285
(V04, 10/2019)
C. Payment of Benefits
1. Return of Total Accumulated Value
a. The TAV to be returned to the member or his legal heirs, less of any and all pending obligations
with the Fund, shall consist of member’s remitted accumulated savings; employer’s counterpart
savings, if applicable; and dividend earnings credited to the member’s account as declared by
the Board.
b. For members with outstanding obligations with the Fund, at the time of termination of
membership, the said obligation shall be deducted from his TAV prior to the release of the
provident claim.
c. Release of member’s TAV shall be based on actual savings remitted by the employee and
employer, if applicable. In the case of member-claimants whose employer counterpart savings
have not been remitted to the Fund, a partial release of their TAV shall be made based on actual
amounts credited to their accounts. In the same manner, the computation of annual dividends
shall be based on actual remittances made. Any amount that the Fund may collect from the
employer due to enforcement shall be subsequently released to the member or his heirs.
d. In case of member’s death, the release of his provident benefit claims shall be in accordance
with the laws on succession.
e. A member who has multiple employers shall be entitled to claim his entire savings anytime upon
occurrence of any of the grounds for membership termination.
2. Death Benefit
a. Upon the death of a member, his legal heirs shall be entitled to receive the applicable death
benefit in addition to the deceased member’s TAV. The amount of the death benefit shall
depend on his membership status with the Fund at the time of his death.
- For active members at the time of death – P6,000, regardless of the amount of TAV.
- For inactive members at the time of death – the amount is equivalent to member’s TAV or
P6,000, whichever is lower.
- If TAV offsetting occurred prior to the member’s death – the amount of death benefit to be
granted shall depend on the membership status as of date of death. In case of inactive status
as of date of death, the TAV under consideration shall be the TAV prior to offsetting.
b. The legal heirs of the deceased member shall still be entitled to death benefit, subject to the
conditions set and under the following circumstances:
- The check for provident benefit claims based on the grounds for membership termination other
than death is not yet released to the member;
- The member’s provident benefit claim proceeds are not yet credited to his disbursement/cash
card or Payroll Account at the time of his death.
3. Manner of Payment
a. Shall be paid to the member or his legal heirs through any of the following modes:
- Crediting to the claimant’s disbursement/cash card or Payroll Account;
- Through check payable to the claimant; or
- Other similar modes of payment approved by the Board.
b. Claiming of checks through a representative shall be allowed provided the representative shall
present the documents that the Fund may require relative to the provident benefit claim.

CHECKLIST OF REQUIREMENTS
BASIC REQUIREMENTS
1. Application for Provident Benefits Claim (APB, HQP-PFF-285)
2. Pag-IBIG Loyalty Card and one (1) valid ID of member/claimant (present original and submit photocopy)
NOTES:
a. If Pag-IBIG Loyalty Card is not available, two (2) valid IDs (present original and submit photocopy).
b. For retirement purposes, the valid IDs must reflect the member’s date of birth. If the valid IDs do not reflect the date of birth, submit any of the following:
 Birth Certificate of Member issued by Philippine Statistics Authority (PSA) or Local Civil Registry Office (LCRO).
 Non-availability of Birth Record issued by PSA and Joint Affidavit of Two Disinterested Persons (HQP-PFF-029, notarized)
ADDITIONAL REQUIREMENTS
A. FOR RETIREMENT
1. Photocopy of Certificate of Early Retirement (Notarized) (For Private Employee only at least 45 years old)
2. GSIS Retirement Voucher (For optional retirement)
3. Photocopy of Order of Retirement (For Members under AFP, PNP, BJMP, BFP)
4. Photocopy of Statement of Service (For Members under AFP) or Service Record (For Members under PNP, BJMP, BFP)
B. FOR PERMANENT TOTAL DISABILITY OR INSANITY/TERMINATION FROM THE SERVICE BY REASON OF HEALTH
1. Photocopy of Physician’s Certificate/Statement (With Clinical or Medical Abstract)
C. CRITICAL ILLNESS OF MEMBER OR ANY OF HIS IMMEDIATE FAMILY MEMBER
1. To establish kinship of the immediate family to the member, the claimant shall submit any of the following:
a. Photocopy of Marriage Contract issued by PSA or LCRO and Advisory on Marriage issued by PSA (If the immediate family member is the spouse)
b. Photocopy of Birth Certificate issued by PSA or LCRO, Baptismal or Confirmation Certificate of the immediate family member
c. Photocopy of Non-availability of Birth Record issued by PSA and Joint Affidavit of Two Disinterested Persons (HQP-PFF-029, notarized)
2. Photocopy of Physician’s Certificate/Statement (With Clinical or Medical Abstract)
D. FOR PERMANENT DEPARTURE FROM THE COUNTRY
1. Photocopy of Passport with Immigrant Visa/Residence Visa/Settlement Visa or its equivalent
2. Sworn Declaration of Intention to Depart from the Philippines Permanently (HQP-PFF-031, notarized) (No need to submit if already based abroad)
E. FOR DEATH
1. Photocopy of Death Certificate of Member issued by PSA or LCRO.
2. Proof of Surviving Legal Heirs (HQP-PFF-030, notarized)
3. Photocopy of Certificate of No Marriage (CENOMAR) issued by PSA (If deceased member is single).
4. Photocopy of Marriage Contract issued by PSA or LCRO and Advisory on Marriage issued by PSA (If deceased member is married)
5. Photocopy of Birth Certificate issued by PSA or LCRO, Baptismal or Confirmation Certificate of all children (if with children)
6. Affidavit of Guardianship (HQP-PFF-028, notarized) (If with child/children below 18 years old, or if child/children is/are physically/mentally incompetent)
7. To establish kinship with the deceased member, the claimant shall submit any of the following:
a. Photocopy of Birth Certificate issued by PSA or LCRO, Baptismal or Confirmation Certificate of deceased member/claimant
b. Photocopy of Non-availability of Birth Record issued by PSA and Joint Affidavit of Two Disinterested Persons (HQP-PFF-029, notarized)
IMPORTANT
1. FOR DOCUMENTS (E.G. BIRTH CERTIFICATE, MARRIAGE CONTRACT, DEATH CERTIFICATE, ETC.) ISSUED ABROAD:
A. IF THE ISSUING COUNTRY IS A MEMBER OF THE HAGUE APOSTILLE CONVENTION, THE DOCUMENT/S MUST BE APOSTILLIZED BY THE CONCERNED
APOSTILLIZATION AUTHORITY/OFFICER.
B. IF NOT, THE SAID DOCUMENT/S SHOULD BE DULY CERTIFIED BY THE PHILIPPINE CONSULATE GENERAL/PHILIPPINE EMBASSY IN THE COUNTRY
WHERE THE DOCUMENT WAS ISSUED.
2. IN ALL INSTANCES WHEREIN PHOTOCOPIES ARE SUBMITTED, THE ORIGINAL DOCUMENT MUST BE PRESENTED FOR AUTHENTICATION.
3. IF MEMBER/CLAIMANT CANNOT CLAIM PERSONALLY, SUBMIT SPECIAL POWER OF ATTORNEY (HQP-PFF-033) AND TWO (2) VALID IDs EACH OF THE
PRINCIPAL AND ATTORNEY-IN-FACT.
 ANNEX A

Guide on Apostille

1. What is Apostille?

Apostille is a certificate issued under the Apostille Convention authenticating the

origin of a public document.

In the Philippines, it replaced the Authentication Certificate as proof of authentication

of a public document by the DFA.

Apostille Convention is an international treaty developed and adopted by Hague

Conference. The full title of the Convention is Hague Convention of 5 October 1961
Abolishing the Requirements of Legalisation for Foreign Public Document.

2. What does an Apostille look like?

As required by Hague convention, each apostille has the title "Apostille", the
reference to Hague Convention, and the following ten items:

(1) Country where the Apostille is being issued;

(2) Name of the official whose signature is being certified by an Apostille;
(3) The position or capacity of this official;
(4) Name of the seal on the attached document,
(5) Name of the city where the Apostille is being issued;
(6) The date when the Apostille is being issued;
(7) Position of the official person who signed the Apostille;
(8) Consecutive number of the Apostille;
(9) The seal of the Apostille issuing agency;
(10) Signature.

Apostilles can be issued in the form of paper, sticker or rubber stamp.

3. How can someone verify an Apostille?

 Recipients of an Apostille may contact the Competent Authority. Contact

information, including phone numbers and website information, are available in the
Apostille Section of Hague Conference website: www.hcch.net.

 Some Contracting States, including the Philippines, maintain an e-Register of their

Apostille issuances viewable online.

4. How to verify a foreign Apostille?

 Go to https://www.hcch.net/en/instruments/conventions/authorities1/?cid=41
or search online for “Apostille Competent Authorities.”

 From the HCCH list, select the issuing country.

 Look for the “e-Register” under “Practical Information.”

 If there is no “e-Register,” use the listed phone number or e-mail address to

contact the Competent authority to request verification.
 ANNEX B
Hague Apostille Country List
As of 14 May 2019

1. Albania 41. Germany 81. Oman

2. Andorra 42. Greece 82. Panama
3. Antigua and Barbuda 43. Grenada 83. Paraguay
4. Argentina 44. Guatemala 84. Peru
5. Armenia 45. Guyana 85. Philippines
6. Australia 46. Honduras 86. Poland
7. Austria 47. Hungary 87. Portugal
8. Azerbaijan 48. Iceland 88. Romania
9. Bahamas 49. India 89. Russian Federation
10. Bahrain 50. Ireland 90. Saint Kitts and Nevis
11. Barbados 51. Israel 91. Saint Lucia
12. Belarus 52. Italy 92. Saint Vincent and the
13. Belgium 53. Japan Grenadines
14. Belize 54. Kazakhstan 93. Samoa
15. Bolivia 55. Korea, Republic of 94. San Marino
16. Bosnia and Herzegovina 56. Kosovo 95. Sao Tome and Principe
17. Botswana 57. Kyrgyzstan 96. Serbia
18. Brazil 58. Latvia 97. Seychelles
19. Brunei Darussalam 59. Lesotho 98. Slovakia
20. Bulgaria 60. Liberia 99. Slovenia
21. Burundi 61. Liechtenstein 100. South Africa
22. Cape Verde 62. Lithuania 101. Spain
23. Chile 63. Luxembourg 102. Suriname
24. China, People's Republic of 64. Malawi 103. Swaziland
(Hong Kong & Macao Only) 65. Malta 104. Sweden
25. Colombia 66. Marshall Islands 105. Switzerland
26. Cook Islands 67. Mauritius 106. Tajikistan
27. Costa Rica 68. Mexico 107. Tonga
28. Croatia 69. Moldova, Republic of 108. Trinidad and Tobago
29. Cyprus 70. Monaco 109. Tunisia
30. Czech Republic 71. Mongolia 110. Turkey
31. Denmark 72. Montenegro 111. Ukraine
32. Dominica 73. Morocco 112. United Kingdom of Great
33. Dominican Republic 74. Namibia Britain and Northern Ireland
34. Ecuador 75. Netherlands 113. Uruguay
35. El Salvador 76. New Zealand 114. Uzbekistan
36. Estonia 77. Nicaragua 115. Vanuatu
37. Fiji 78. Niue 116. Venezuela
38. Finland 79. North Macedonia,
39. France Republic of
40. Georgia 80. Norway