Department of National Defense

PHILIPPINE VETERANS AFFAIRS OFFICE

Veterans Compound Camp General Emilio Aguinaldo Quezon City

Date Issued 9/6/2022 2:51:39 PM

Attach LATEST
Control No: BRAF ONLINE2606
2X2
Picture
Issued by: Elizabeth C. Rivera
OIC, Finance Division

BANK REMITTANCE APPLICATION FORM

(Please print all information)

NAME OF VETERAN DELA CRUZ, DOMINADOR SANSANO

NAME OF PENSIONER DELA CRUZ, ROSITA MENDOZA
CLAIM NUMBER OW-MCO-09-004580 DATE OF BIRTH 2/9/1961
PRESENT ADDRESS GANDUZ PANTABANGAN NUEVA ECIJA
PREVIOUS ADDRESS GANDUZ PANTABANGAN NUEVA ECIJA
TYPE OF PENSION

Old Age Pension - Spouse

MINOR

THE ADMINISTRATOR REQUEST FOR CHANGE

Philippine Veterans Affairs Office Bank
Camp Emilio Aguinaldo BANK AMWSLAI TO LBP
Quezon City

Sir/Madam:
I have the honor to request that my monthly pension/s be remitted through my INDIVIDUAL PVAO
PENSION ACCOUNT in the following Bank /Financial Institution according to the terms and conditions imposed
by PVAO and the bank/financial institution:

NAME OF BANK _____________________________________________________________________

ADDRESS/BRANCH __________________________________________________________________

ACCOUNT NUMBER _________________________________________________________________

REASON ____________________________________________________________________________

THUMBMARKS
LEFT RIGHT Witnesses to thumbmarks if pensioner cannot sign

_______________________
Signature over Printed Name

_______________________
Signature over Printed Name

Very Truly Yours,

DELA CRUZ, ROSITA MENDOZA

Signature over Printed Name

This bank/financial institution the name of which is stated above, agrees to credit the pension of the
pensioner for credit to his/her individual PVAO pension account.

BANK MANAGER_______________________________ DESIGNATION______________________

Signature over Printed Name DATE ACCOUNT OPENED____________