APPLICATION FOR (iin oe) (Ji PROVIDENT BENEFITS (APB) CLAIM [PoE A) ovaries iy neers Pettis ack bck noe sg eet pg) | Tipe On PNT ENTS Sa aa rec TD poREReCwra TO GRINCAL LANES OF THE MEMBER OR ANY OF HSC DEATH tar tert Motar 1D exrarrure 1 Wore Pap tc nara) LASTHAME —FIRSTHAME WAMEEXTENSION (og. F.f) MODLENAME —-MADENNAME | Past 4D H.R MADoLopA Wen Aerrgarrro Meena | 10G0~ L4G - LOY7 DATE OF STH aT STATUS DEBRED ANOUNT er ers ti ocr 44, IFT] 2 ati oie | __1_m ‘CLAMANT arti ie Meriter Name, Fist Name, Nae Extensor, Hide Nae) ‘RELATIONSHIP TO WENGER ee TT IMEMGERICLAMANT CONTACT DETAILS Urwcen a, Fox” Butdng Name LotR ecko, Phase No Howse No, SteetNeme sundveion | Uouwnmrsanenreos, reconean | may ey este Sx wma 22 —fegppane S| ine naar TnaiSeaiy Promos a) z Meme PARADA WALD ZEA MET Bo “Wants Langa ‘atoonna, oor cutrgtime, Lathe, No Pusch Hari, SteaName sib | pene enn [ aIs 23d _feprure S pega pees Soman aay Preheat ab coo [te KaLavAHan, Dovalianes, 6:0: SUES Siena semesters oon wat ea esau ae scam as ae acer ttre | 7 er owt bene sj of som an op te soe a arena sa oa wl a Sino" eninosre onto Pap WG Fane as na on son ey ey a dr N06 (Sek npn avr Pap Sn ee ny autos Pap IG Fund dics, stt an sar or exhnge ey omy scour fran ep nd goverment |_uereTwuwe | | pacer we, ‘alg mn nan oA, Kins Gt Py A 2), raed ote tne ol oD A TS Fo | catty hath inemaon an ay "ry wer 0 bray a 9 2 PrEES ie ara — ras 1 IRECENED EY oaTe REVENED EY ORIE APPROVED EY, Dae THIS FORM MAY BE REPRODUCED. NOT FOR SALEHoP-prF-285 (os, 05023) GUIDELINES AND INSTRUCTIONS. Anvnen to Fo “The Appcaton ox Provident Bones Gaim (APB) HOP-PFF-285) may be 1h arcs any ef ong ‘Meme'hip Mat cal be Bases.on 20 yar of membership wh {he Fur, reckaod rom ho ral conten ta ie ecorded ihe Aaibase: provided, he manbor hos remedial of 240 may ‘emborship savings oth Fund tthe te of matty 12 etter a momar sha be conpulsony rebrod unde the Fund lon eating the ago of 8. A momber may otto rte car undar {he Fund wean the aozonce fay of he ong ever 1 ctil reer rom he S89, CS, or fom goversma serves by ‘poset of owe b Rotromon under a prvato employs providenatromont plan, ‘ono tal the mesbor ft Toast 45 years ago tte tec «Rac io age of ity (0). 3. Permanent Tota Diaby (PTD) x san PTD ers o teas oF Impairment ofa phys or mortal urcten resin om ijay oe Soenesy, which Icapactfes sid mombor to paren ary Won roagein any basgans or craton ‘4. Tomnaton fom Serice by Reason of Heath - a member can no Tonge render sores fo an arpoyer do to saver eh conn, a5 corey Nis doctor ‘5 Cia ines of the member o any of is nmedl farily mera, 6 cefied by 2 Komeed pyeican, under any of Bo folowing ago, uber fe approval of Depuy Chet Execute fear” 2 Cancer Onan Fale ©. Heat rltd ness , Newromuscuareitd ess ‘The inmedt omy moribrnlais ny ofthe owns: ='Spoime Pare 2 Caren £ Grandprens opal adopted hien shat on be included nota a ppations ‘wihranal of savings fh approval mot or adoptees pti Windrawal of Pags21G Savings ‘Mombors of to Fue afar the etecty of LA. 967 sal hve the ‘ton to whom his oF her TAV on the centh (15°) year ot ESrinuou membesip. Ts opson may be sxersed ony ance ‘zing he mers torn Amador alge for optonl withowa! ater comping 100 ‘ontnuous moth savings ay opto waharaw an amount ee tan {he equate um of eid 180 mend savigs. The romaning TAY {ogather wih succeeding savings shal bo raearad fo te membor thon tho eccurenes ef any of the. gourds for membontp term 18. Parmanen! Departs om the Country -a member has bean permite by he hot count ean Ure nto has permanent ‘he Phipinoa tres another county. 8, Expats 40, Mosed PagsB1G (M2) 11, Any cer reasons 2¢ ay be approved for bythe Boor 8. Who May Fl “The applaton maybe fed by the membe, is guaran, o any atorzsd ‘eorecertavels tthe reason for clam is dea of the mame, he _ppleation may be fle by his hers orth ators representatives, any Sepotted coun admnitnter or econ ©, How to File {Fling of appt atthe ranch 1. Secu the Appeal for Poidont Sonat (APS) Clan fom any PapiSic Fond bench or downioad worn PaplsIG webate ot sewupaptiohind och ‘Recomplsh ona (1) coy fhe splcaton fom. Fer rloaing of cam procaas tough Payrll Accaut Card! Debursement Cart” ‘atgcn the” phetocopy ef payal sceouldsburemert cadtepost sip (6 nowipopored secant (tent poten oft car ny). 4, Submit the socomplshed eppiition frm, together wih roquted Socumons te any PaptBIG Fund branch. Processing of ci hal ‘mance en Upon submission of complete docuants Fling of aplication threughonine ‘To caine tig tough Viti! PagtBIG shall be apostle 19 the {olling grands en: tReet” 1 Gptonal wanaraval (15 years) 2 Med PagtoiG W (MP2) atu 1, Prepare phottscanos copy ofthe folowing documents: = Acomplined Apliation for Proven Bonfts (APE) Cnkn 2 One (yaa 1 Spgetng documents Sef pot showing car 2. Aecess the Vital PagdBIG at the Pag 1B Fund website ade he ‘epleaton tor ovat bent a . Payment of Benois 4. Ret ot Total Accumulated Value {2 The TAV tobe retuned tthe mamber hi ga he, les of ny and penn aaigaton whe Fun, sal conse of members emated ‘Sctumulated savings: employe'cotnterpart sav, Fapptcae: ard ‘Second aarangs creed tothe members account te Sere by He ‘Bore », Formombors wih utstnsing batons whe Fund then of {ermnatono menbershp he sod cbigaton shel be Gece Hom Fis TAV prot aan fhe prover ex « Reemns of embers TAV shal be bane on atl savings rites by the erpioqeo and empoye.F appcabl. Inthe avs of amber tlamants whose employer sonra savings haven oon reed {othe Fund, para lado hor TAV shall be made based on actus ‘mounts cedied to ther aosunt. in the same manne the ryt of anus des shal bo Bases on seal emaneas ‘ado. Any amount that Fur may eae! fom ho employer de 0 orcomant shal be sutsequenty lense oho moma orishas 44 Inease of members death, to lease of hs prvaor Bonell cas ‘Shall be in Seoowance wth he lawson eucoeesn -Aimember who has mull employers shal be ented to cam his cai sma enine wien crue of ny the gander 2. Death Benast 2. Upon tho death of mone, is egal irs sha be enti to eaive ‘He apes doath banat h nn ote docoasod member's TAV ‘Tho amount the death bent shal depend on he members ts ‘th ho Fund atthe uma hie death “For acve mamas athe tine of death — 6,00, regards ofthe For nacive manors the time of dath — tho amounts equivalent ‘omember TAY or PAN, whichever nor -IFTAYofestng oscar pce tote monbers death the amon of

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