CR: OASAFC-2022-06-30-003

RSCN-2022-10-20-077

2022-132
OCT 20, 2022
DILG - NBOO
DBC Form 001

APPLICATION FOR BARANGAY OFFICIAL'S DEATH BENEFIT CLAIM

Instruction: This form shall be accomplished by the claimant and

submitted immediately to the DILG HUC/ICC/CC/Municipal
Office.

NAME OF BARANGAY OFFICIAL:

POSITION:
BARANGAY:
CITY/MUNICIPALITY:
PROVINCE:
DATE OF ELECTION/APPOINTMENT:
DATE OF DEATH:

SIGNATURE OVER PRINTED NAME OF CLAIMANT

DATE ACCOMPLISHED

ATTACHMENT:
 DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT Document Code
FM-SP-DILG-07-01
CITIZEN'S CHARTER SERVICE REQUEST FORM Rev. No. Eff. Date Page
(As of December 1, 2021) 00 06.15.21 1 of 2

SERVICE TITLE: ONLINE PROCESSING OF REGIONAL DEATH BENEFIT CLAIMS FOR REFERENCE NO.
DECEASED BARANGAY OFFICIALS (DBCDBOS) FOR FUND ALLOCATION BY THE DATE OF REQUEST
DBM NAME OF CLIENT/ORGANIZATION:
Kindly Check the
Documentary Requirements
documents Needed
1. Accomplished DBC Form 001
2. Oath of Office CONTACT DETAILS:
3.Certificate of Incumbency (Issued by the DILG C/MLGOO or
Punong Barangay)
4. Certified true copy of Death Certificate of the deceased
barangay official
5. Photocopy of Government-issued ID of claimant OTHER NEEDED INFORMATION, if any:
Claimant’s documents whichever is applicable: Original or
Certified True Copy
a) Marriage Certificate, if the claimant is the widow/widower of
the deceased barangay official
b) Birth Certificate, if claimant is a son/daughter of the SIGNATURE:
deceased barangay official
c) Birth Certificate of the deceased or affidavit of two
disinterested parties, if the deceased barangay official is single
and the claimant is his/her parent/brother/sister. RECEIVED BY: DATE AND TIME RECEIVED
d) In case of multiple designated beneficiaries/claimants of
deceased barangay officials, only one check shall be issued to
the person whom the beneficiaries agreed from among
themselves to receive the check. Provided, however, that a
Special Power of Attorney shall be executed as supporting
document.
e) A designated beneficiary/legal heir who is a minor shall be
represented by a guardian. An affidavit of Guardianship shall be Receiving Officer
executed for the purpose. ENDORSED TO RESPONSIBLE OFFICER: DATE AND TIME ENDORSED
Other supporting documents:
f) Photocopy of Police Report, in case the matter of death of the
deceased barangay official is not a natural cause
g) Joint Affidavit of Two (2) Disinterested Persons or
Photocopy of Birth Certificate in case of discrepancy in the
name of the deceased barangay official
h.) For beneficiaries of IPMRs, if applicable, in the absence of the
documents mentioned above, affidavit of two (2) disinterested
parties shall be required.
i) Other supporting documents
REMARKS: Name/Unit and Designation

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ACKNOWLEDGEMENT RECEIPT
This is to acknowledge the service/s you have requested: REFERENCE NO.
Date Received Expected Date Date of Release
Service Title: Online Processing Of Regional Death of Release in case of extension
Benefit Claims For Deceased Barangay Officials
(DBCDBOS) For Fund Allocation By The DBM
Republic of the Philippines
DEPARMENT OF THE INTERIOR AND LOCAL GOVERNMENT
NAME OF RESPONSIBLE OFFICER/UNIT/DESIGNATION: CONTACT DETAILS:

OFFICE ADDRESS:

REMARKS:

Prepared By Reviewed By Approved By

Process Owner Division Chief NBOO Deputy QMR