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03102014-MPRQ GSIS Memorial Plan Release and Quit Claim Form

GSIS claim form for memorial plan release and quit

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Form No. 03102014-MPRQ

GSIS MEMORIAL PLAN
RELEASE AND QUIT CLAIM FORM
I, ____________________________________________________________, having
acknowledged receipt of the amount of _____________________________
______________________________________________ (PhP ________________) as refund
of total premiums paid/ premiums paid for my GSIS Memorial Plan, and after cancellation
of my GSIS Memorial Plan, hereby release and forever discharge the Government Service
Insurance System (GSIS) from all its obligations and liabilities under Plan Agreement Number
____________________.
I hereby waive and release GSIS from any further action, cause of action, demand,
damages or any claim whatsoever against the GSIS, on account of my application for
Enhanced Optional Exit Mechanism (EOEM), provided that I actually received the proceeds
of my claim.
I hereby state that I have carefully read, and understood the foregoing release and
quit claim, and agree to its terms freely and voluntarily.
Signed at ____________________ this ______ __________________ 20____.
(day)
(month)
(year)

__________________________
(Signature of Planholder)
Note: To be filled up if paid thru check

Check No.

:

Date

:

Amount

:

Drawee Bank

:

Signed in the presence of:

(Signature over Printed Name)

(Signature over Printed Name)
 
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