CRMDFormNo.

06-08-2010/rpa

GSISMEMBER’SREQUESTFORM

Date:11-29-2022 Time:7:38Pm
Name:RobertV.Pring
(pleasewritefullnamewithmiddleinitial)
GSISPolicyNo./RetirementNo. 2005425303 GSISIDNo. 021193178916
Agency/OfficeAddress: TARLA CNATIONALHIGHSCHOOLANNEX/MALIGAYA,SANMIGUEL,TARLACCI
MailingAddress: 172Manlapig, Capas,Tarlac
Tel.No.(Office Landline): N/a ResidenceLandline:
FaxNumber: N/a CellphoneNo.: 0915
E-mailAddress: robert.pring@deped.gov.ph For DEP ED:Employee No. 540298 9 STNNo. DIV.No. 049

Natureof Business/Request/Transaction(Pleasecheckappropriatebox):
LoansTransaction DateFiled MembershipTransaction DateFiled
ConsolidatedLoan IssuanceofBusinessPartnerNo.
PolicyLoan Re-insurance

HousingLoan ConversionofLifePolicy(ELP)
✓ Refund/Recomputation Requestforduplicatecopyofcontract
RequestforGSISClearance Changeofname/status/birth
Others: Others:

ForDEPEDEmployees DateFiled CLAIMS DateFiled

Requestforstoppageofloandeduction CSV
Requestfordeductionofloanamortization Maturity
Retirement/Survivorship
Burial
E-SERVICES DateFiled DeathClaim
PensionLoan CEAP
OldAgePension HIP
SurvivorshipPension Pre-need
CommencementofPension EC
AccrualofPension OLID
RequestforHomeVisit Disability
Others:
POSTING DateFiled
Others:
OtherTransactions Others:
Specifytypeofloanandpaymentmonthsandyear
DetailsofRequest:

My refund for the month of october 2022,I was deducted in computer loan and gfal and I have fullipaid it last september 2022

MSO’sAnalysisandRecommendation:

Signatureoverfullnameoftransactingmember SignatureoverfullnameofattendingMSO
ROBERT V. PRING