Please Use BLUE BALLPEN

CERTIFICATION
For Deceased Pensioner

This is to certify that ____________________________________

(Name of deceased social pensioner)

died on _________________. His/her social pension for the period of

(date of death)

________________________ in the amount of ___________________

(Period covered) (Amount in words)

________________________________________ (P ______________)
(Amount in Figurer)

shall be claimed by Mr./Ms. ___________________________________,

(Representative of the deceased)

whose signature appears below, the _______________________ of the

(Relation to the deceased)

deceased and is hereby authorized to claim the stipend.

_____________________________
(Signature of Authorized Representative)

Certified by:

_________________________________________________________
(Printed name over signature of MSWDO/OSCA Head/Brgy. Captain)

Instruction:

Accomplish in 2 copies (1 original and 1 photocopy)

Submit photocopy of death certificate of social pensioner (1 Certified true copy and 1 photocopy)
Submit photocopy of ID of social pensioner (2 copies)
Submit photocopy of ID of the authorized representative (2 copies)