Quarterly Wellness Check and Visitation Certification

This is to certify that, I ____________________________________, assigned at

Rank & Full Name
______________________________, with CP #___________________________, is the
designated Active Personnel-Buddy of _________________________________________.
Rank, if applicable, & Full Name of Pensioner-Buddy

I have established initial contact with my Pensioner-Buddy on ________________

at ______________________________________________________________________.
House #, Street, Barangay, City/Municipality, Province, Region
My Pensioner-Buddy uses CP # ________________________, and his/her Next-of-Kin or
Trustee/s is/are ___________________________________________________________
with CP # ____________________________.

I certify that my Pensioner-Buddy is:

Alive and well Deceased Re-Married

Reached Age of Majority Changed Citizenship
TPPD beneficiary for _____ years
Allottee of __________________________ who is Alive and well
Deceased
In case of any disqualification above, I am attaching with this Certification the:
Death Certificate
Original PSA LCR
Photocopy
Marriage Contract
Original : PSA LCR
Photocopy :
Birth Certificate
Original : PSA ; LCR ; Church
Photocopy :
Advisory on Marriages
Original : PSA ; LCR
Photocopy :
Joint Affidavit
I am further attaching a picture of myself with my Pensioner-Buddy (who is holding
the latest newspaper/printed headline), his/her Update Form and Affidavit of Undertaking.

Lastly,I certify to that the foregoing information are true, correct and complete.

_____________________________________
Rank, Complete Name and Signature

SUBSCRIBED AND SWORN to before me this ______ day of ________________,

20__, in _____________________________, Philippines.

_________________________________
Administering Officer