CEAP RB FORM NO - CEAP Retirement



CEAP Retirement Form No. 9 (revised)

CATHOLIC EDUCATIONAL ASSOCIATION OF THE PHILIPPINES RETIREMENT PLAN

APPLICATION FOR BENEFITS

I hereby respectfully apply for the benefits to which I am entitled to in accordance with the following:

| | |Normal Retirement Provision | |

| | |Optional or Early Retirement Provision | |

| | |Late Retirement Provision | |

| | |Disability Provision | |

| | |Separation Provision | |

| | | | Resignation/Voluntary | |

| | | | Redundancy/Retrenchment | |

| | | | Medical/Involuntary | |

| | |Dismissal for Cause/Termination | |

|Hereunder are pertinent personal information needed for processing of my benefit claim: |

|____________________________________________________________________________________________ |

|LAST NAME FIRST NAME MIDDLE NAME |

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|Maiden Name (if female, married applicant) |

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|Gender |

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|Date of Birth |

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|Date of Hire |

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|Date of Separation/Retirement |

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|Tax Identification Number |

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|Personal Exemption |

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|Additional Exemptions (only children below 21 yrs old) |

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|Spouse claims additional exemption? Yes/No |

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|Gross Taxable Income for Current Calendar Year* (Item 25 of BIR Form 2316) |

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|Tax Withheld for Current Calendar Year* |

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|Employer’s Last Month-period of Contribution / Remittance Date |

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|Employee’s Last Month-period of Contribution / Remittance Date |

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|Period of Leave without Pay, if any |

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* Note: 1) Gross Taxable Income earned with the present Employer from January until the month of resignation /

separation of the current calendar year should be net of statutory deductions (i.e. SSS, Philhealth, Pag-ibig,

Non-Taxable 13th Month Pay, De Minimis, etc.)

2) Tax withheld from January until the month of resignation/separation of the current calendar year

Example: Date of Resignation - March 2014

Taxable Gross Income for Current Calendar Year (i.e. Jan-March 2014)

Tax Withheld for Current Calendar Year (i.e. tax withheld from Jan-March 2014)

The manner of payment is lump sum. I understand that all the benefit payments to which I am entitled under this Plan will be made in accordance with the rules and regulations of the Catholic Educational Association of the Philippines Retirement Plan. I also recognize the right of the Retirement Commission to verify the correctness of the information contained in this application and agree to furnish proofs if required to do so.

_______________________________________ _______________________________________________

Name & Address of the School Signature Over Printed Name of Applicant/Claimant

_________________________________________ ___________________________ ______________

Signature Over Printed Name Designation Date

of Authorized Signatory

(To be accomplished in triplicate)

Distribution: 1 copy for CEAP Retirement Plan Office

: 1 copy for Trustee bank

: 1 copy for school

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