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YVOP Form FINAL PDF

The document is a yearly verification form for pensioners of the Philippine Coast Guard, requiring personal and beneficiary information. It includes a questionnaire regarding employment status, marital status, and dependent children, along with instructions for submission. Specific requirements are outlined for different categories of pensioners, including those living abroad or with medical conditions.

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Arkim Dela cerna
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47 views3 pages

YVOP Form FINAL PDF

The document is a yearly verification form for pensioners of the Philippine Coast Guard, requiring personal and beneficiary information. It includes a questionnaire regarding employment status, marital status, and dependent children, along with instructions for submission. Specific requirements are outlined for different categories of pensioners, including those living abroad or with medical conditions.

Uploaded by

Arkim Dela cerna
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PHILIPPINE COAST GUARD

COAST GUARD HUMAN RESOURCE MANAGEMENT COMMAND


COAST GUARD RETIREMENT AND BENEFITS ADMINISTRATION SERVICE

YEARLY VERIFICATION OF PENSIONER’S FORM


C.Y. ________
THIS FORM IS NOT FOR SALE
PLEASE READ INSTRUCTIONS AND REMINDERS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL
INFORMATION IN CAPITAL LETTERS AND USE BLACK INK ONLY.
PART I – MEMBER’S / PENSIONER’S INFORMATION
TYPE OF RETIREMENT
Compulsory Optional Posthumous Complete Disability Discharge Beneficiary

Serial No. of Pensioner Rank of Pensioner Date of Birth Date of Retirement


(MMDDYYYY) (MMDDYYYY)

(SURNAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)

LOCAL ADDRESS (RM/ FLR/ UNIT NO. & BLDG NAME) (HOUSE/ LOT & BLOCK NO.) (STREET NAME)

(BRGY/ DISTRICT/ LOCALITY) (SUBDIVISION) (CITY/ MUNICIPALITY) (PROVINCE)

TELEPHONE NO. MOBILE/ CELLPHONE NO. E-MAIL ADDRESS


(Area Code + Tel No)

FOREIGN ADDRESS (If applicable)

COAST GUARD DISTRICT (COVERED) COUNTRY ZIP CODE

PART II – LEGAL BENEFICIARY’S INFORMATION


NAME OF LEGAL BENEFICIARY
(SURNAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX) AGE DATE OF BIRTH

LOCAL ADDRESS RELATIONSHIP TO THE PENSIONER

MOBILE/ CELLPHONE NO. IF RECEIVING PENSION AS GUARDIAN, INDICATE NAME:


(SURNAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)

PART III – QUESTIONNAIRE


1. FOR TOTAL DISABILITY / RETIREMENT PENSIONER, HAVE YOU BEEN RE – EMPLOYED / RESUMED
SELF – EMPLOYMENT? YES NO
IF YES, NAME AND ADDRESS OF PRESENT EMPLOYER: ____________________________________________
DATE RE-EMPLOYED OR RESUMED SELF – EMPLOYMENT: _________________________________________
2. FOR DEATH PENSIONER, HAVE YOU RE – MARRIED OR CURRENTLY COHABITING WITH ANOTHER
PERSON? YES NO
IF YES, NAME OF SPOUSE/ PARTNER: _________________ DATE OF MARRIAGE/ COHABITATION: _________

1 | 3NOTICE:Anyone who falsifies essential information requested by this or a related from may, upon conviction, be subject to fine and
imprisonment under the law.
3. ARE YOU UNDER THE CARE AND CUSTODY OF A GUARDIAN?
YES NO
IF YES, NAME AND ADDRESS OF GUARDIAN: ____________________________________________________

4. IS THERE ANY DEPENDENT CHILD WHO ARE BELOW 21 YEARS OF AGE AND STILL SINGLE?
YES NO
IF YES, FILL OUT THE DATA BELOW:
NAME OF DEPENDENT DATE OF
NAME OF GUARDIAN OCCUPATION
(Children below 21 y/o) BIRTH
1)
2)
3)
4)
5)
6)
7)
8)
I HEREBY CERTIFY that the foregoing information is complete, true and correct to the best of my knowledge.

__________________________ __________
Signature over printed name Date

(If unable to sign, affix fingerprints with the signature of two (2)
witnesses and submit photocopy of one (1) valid ID with photo
and signature of each witness) LEFT THUMB RIGHT THUMB

WITNESSES:

1) _____________________________ ________ 2) ____________________________ _________


Signature over printed name Date Signature over printed name Date
PART IV – CERTIFICATION OF BARANGAY CHAIRMAN/HRMU REPRESENTATIVE
(FOR RETIREE AND SURVIVOR PENSIONERS)

THIS IS TO CERTIFY that Mr./ Ms. ______________________, a depositor/ bonafide resident of

____________________________________________personally appeared before the undersigned on

______________________ as compliance to the annual confirmation of pensioners being conducted by the

Office of the Philippine Coast Guard Retirement and Benefits Administration Service.

___________________________ _________
Signature over printed name Date

2 | 3NOTICE:Anyone who falsifies essential information requested by this or a related from may, upon conviction, be subject to fine and
imprisonment under the law.
FOR LOCAL RESIDENT PENSIONERS :

ABLE TO REPORT PERSONALLY UNABLE TO REPORT PERSONALLY

✓ Accomplished YVOP Form ✓ Accomplished YVOP Form


✓ Photocopy of Pensioner’s ID & one (1) ✓ Photocopy of Pensioner’s ID & one (1)
Valid ID(front and back) with three (3) Valid ID(front and back) with three (3)
signatures signatures
✓ Proof of Life
- Whole body picture holding any
current newspaper/calendar (date
must be clearly indicated)

FOR QUALIFIED BENEFICIARY OF DECEASED FOR PENSIONERS LIVING ABROAD:


PENSIONERS :

✓ Accomplished YVOP Form ✓ Accomplished YVOP Form


✓ Photocopy of Pensioner’s ID & one ✓ Photocopy of Pensioner’s ID & one (1) valid
(1) Valid ID with three (3) signatures ID with three (3) signatures
✓ Photocopy of PSA CENOMAR ✓ Photocopy of valid passport or two (2) Valid
(if child) ID issued by host country Governmental
✓ Photocopy of PSA Advisory on unit/agency
Marriage (if spouse) ✓ Proof of Life
✓ Proof of Life - Whole body picture holding any
- Whole body picture holding any
current newspaper (date must be
current newspaper/calendar (date
clearly indicated)
must be clearly indicated)

FOR CONFINED OR WITH MEDICAL CONDITION FOR INQUIRIES,


AT HOME: YOU MAY CONTACT US AT :

✓ Accomplished YVOP Form


✓ Photocopy of Pensioner’s ID & one (1)
Valid ID with three (3) signatures
✓ Medical Certificate (Government or
Private Hospital)
✓ Proof of Life
- Whole body picture holding any RETIREMENT AND BENEFITS ADMINISTRATION SERVICE
current newspaper (date must be clearly Address: Ground Floor, Citadel Building, 637
indicated) Bonifacio Drive, Port Area, Manila
Facebook: www.facebook.com/PCG Pension
and Gratuity Management Center
E-Mail: [email protected]
Mobile Nr: 09260646613 - GLOBE
09287264445 - SMART

3 | 3NOTICE:Anyone who falsifies essential information requested by this or a related from may, upon conviction, be subject to fine and
imprisonment under the law.

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