PENSIONER’S INFORMATION FORM

RETIREE TRANSFEREE (RELATIONSHIP)

Category: SPOUSE
PNP CHILD
INP If PWD, Ailment __________
Mode of Retirement: PARENT
COMPULSORY GUARDIAN Latest 2x2 Picture
OPTIONAL

PENSIONER’S INFORMATION
LAST NAME FIRST NAME MIDDLE NAME QUALIFIER

Date of Birth (MM/DD/YYYY) Age Contact Number Landbank Branch (preferred branch where the account
will be opened):

ADDRESS
House No. & Street Subdivision Barangay District

Municipality City Province Region

Religion Citizenship Gender

Male Female
Height (cm) Weight (kgs) Blood Type Color of Eyes Color of Hair Prominent Facial Features (mole, birthmark, scars, etc.)

IF RETIREE
Badge Nr. Rank Date Entered the Service Date Retired Last Unit Assignment (specify name of unit and
address)

IF TRANSFEREE
Please indicate below the information about the Principal Retiree
LAST NAME FIRST NAME MIDDLE NAME QUALIFIER

Badge Nr. Rank Date Entered the Service Date Retired/Separated Date of Death

Person/s to be notified in case of emergency / Attorney-in-fact

NAME ADDRESS CONTACT NUMBER

I certify that the information herein are true and correct to the best of my knowledge. I have affixed my signature
and/or thumbmark to attest to the truthfulness and correctness; thereby, I may be held liable for prosecution on any
misrepresentation hereof.

LEFT RIGHT SIGNATURE

DATE SIGNED

TO BE FILLED OUT BY AUTHORIZED PERSONNEL (Signature over printed name)

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