BSB Form No. 2-A s.

2023

Republic of the Philippines

Province of Leyte
MUNICIPALITY OF BURAUEN

APPLICATION FOR DEATH BENEFIT

Instructions: This form shall be accomplished by the claimants and shall be endorsed by the Punong Barangay, in case of
Sangguniang Bayan Members, appointive of cials and barangay service personnel, or by the DILG Of cer, in case of Punong
Barangays. This application shall be submitted to the Of ce of the Municipal Mayor through the Punong Barangay or DILG Of cer,
as the case may be.

NAME OF BARANGAY OFFICIAL : ____________________________________

POSITION : ____________________________________

BARANGAY : ____________________________________

CITY/MUNICIPALITY : ____________________________________

PROVINCE : ____________________________________

DATE OF ELECTION/APPOINTMENT : ____________________________________

DATE OF DEATH : ____________________________________

______________________________________________
(Signature over Printed Name of Claimant)

___________________________
(Date Accomplished)

Evaluation ———————————————————————————————————————————

DENIED due to : ___________________________________________ Recommending Approval

FOR COMPLETION OF REQUIRED DOCUMENTS:

___________________________________________________________ _______________________________________
RECOMMENDED FOR APPROVAL Signature over Printed Name
Recommended Amount: ₱ 20,000.00 ₱ 15,000.00
₱ 10,000.00. ₱ 5,000.00
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