PVAO-CBA-18-06
REPUBLIC OF THE PHILIPPINES
Department of National Defense 2” x 2”
PHILIPPINE VETERANS AFFAIRS OFFICE PASSPORT
Camp General Emilio Aguinaldo, Quezon City SIZE
PICTURE
(CLAIMANT)
APPLICATION FOR BURIAL ASSISTANCE
(READ INSTRUCTIONS AT THE BACK BEFORE FILLING-UP THIS FORM)
LAST, FIRST & MIDDLE NAME OF APPLICANT (LEAVE THIS SPACE BLANK)
CLAIM NO :
ADDRESS: Street: RECEIVED BY:
Town/City:
Province: DATE :
ZIP CODE:
RELATIONSHIP OF APPLICANT
TO THE DECEASED VETERAN VERY IMPORTANT
Veteran is a PVAO Pensioner.
LAST. FIRST & MIDDLE NAME OF DECEASED VETERAN
Veteran is not yet a PVAO Pensioner.
RANK: SERIAL NO.: MAJOR SERVICE: NATIONALITY:
DATE OF DISCHARGE: LAST UNIT OF ASSIGNMENT:
DATE OF DEATH: PLACE OF DEATH:
CATEGORY OF VETERAN: (CHECK PERTINENT ITEMS ONLY)
WAR VETERAN POST-WAR VETERAN
WWII Veteran Korean (PEFTOK) AFP-Phil. Army(PA) AFP-Phil. Air Force(PAF)
Vietnam(PHLCAG) Philippine Scout AFP-Phil. Navy(PN) AFP-Phil. Constabulary(PC)
CERTIFICATION AND SIGNATURE: (READ CAREFULLY BEFORE SIGNING)
I HEREBY CERTIFY that:
1. The foregoing entries and attached supporting documents are true and correct; and
2. I am fully aware of the consequences of committing fraud in connection with this application.
In witness whereof, I have hereunto affixed my signature and thumbmarks this ____________ day of ____________ 20___.
THUMBMARKS
Of Claimant
Signature : ____________________________________________________
LEFT RIGHT (Applicant)
Type of Government Issued ID: ______________________________
ID No. : ______________________________
Validity/Expiration Date : ______________________________
SUBSCRIBED AND SWORN to before me this ________ day of _____________ 20____at ________________________, affiant
exhibiting to me the Residence Certificate/ Passport/ Identification Card as indicated above.
Signature of Administrative Officer:
Printed Name:
Official Designation:
(PLEASE SEE INSTRUCTIONS AT THE BACK) Rev 01 S. 2018
Issued by :
Date :
APPLICATION FOR BURIAL ASSISTANCE
DOCUMENTARY REQUIREMENTS
( )1. Proof of Military Service ( )4. Official Receipt (OR) / Certification of Funeral
Expenses (Funeral Parlor/ Memorial Plan)
1.1. For Retired PA/ PM/ PN/ PAF – Military
Service Record (MSR) from NRD-OTAG If the OR is not under the claimant’s name,
(Disregard if veteran is already a PVAO kindly secure waiver of rights from the payor
pensioner) together with his/ her valid IDs.
1.2. For Philippine Constabulary – Statement of If the Plan Holder is the veteran and the
Service from PNP – Crame and MSR from claimant is other than wife, Waiver of Rights
NRD OTAG of majority of all the children must be
1.3. For Killed-in-Action & Died in Line of Duty: executed together with their valid IDs.
1.3.1. Statement of Service For Islamic Burial rites: In the absence of
1.3.2. Line of Duty Status OR, Notarized Affidavit of Burial Expenses
1.3.3. Casualty Report and receipts of burial expenses will do. (E.g.
1.3.4. Declaration of Legal Beneficiaries White Cloth/ Wood)
( )2. Death Certificate of Veteran (either from the ( )5. Valid I.D. of Claimant
Local Civil Registrar or the Philippine Statistics
Authority)* ( )6. Barangay Certificate
( )3. Proof of marital relationship or filiation of ( )7. 2x2 I.D. picture (2 pcs./ white background/ no
applicant to the veteran* eyeglasses) of claimant
1.4. PSA-issued Marriage Contract, If spouse.
1.5. PSA-issued Birth Certificate* or Marriage
Contract, If child.
IMPORTANT REMINDERS
1. This application form is provided FREE by the Philippine Veterans Affairs Office (PVAO). IT IS NOT FOR SALE. Do not
reproduce, sell or buy this form. Only the authenticated official form bearing a set number will be accepted by PVAO for
processing;
2. All requirements must be original/ Certified true copy. Photocopies are accepted upon presentation of original documents;
and Burial Assistance claim is valid only for two (2) years upon the death of the veteran;
3. Fill out TWO copies only. PRINT ALL ENTRIES. The accomplished application form may be subscribed and sworn to
before any authorized to administer oath: or before a PVAO Field Extension Service Office, PVAO Administering Officer at
no cost to the applicant;
4. For Delayed-Registered Death Certificate, the following shall be submitted:
(a) Affidavit of Delayed Registration which shall be executed by (a) the hospital or clinic administrator if the person died
in the hospital, clinic or similar institution; or (b) if the person died elsewhere, by the attendant-at-death; and (c) In the
default of the hospital or clinic administrator or attendant-at-death, the affidavit shall be executed by any of the nearest
relative of the deceased, or by any person having legal charge of the deceased when he was still alive.
(b) Authenticated copy of the certificate of burial, cremation, or any other means of corpse disposal.
5. For Delayed-Registered Marriage Certificate, the following shall be submitted:
(a) Affidavit of delayed registration which shall be executed by: (a) The solemnizing officer; or (b) the person reporting or
resenting the Certificate of Marriage; (c) Two (2) disinterested persons who have personal knowledge of the marriage
preferably the sponsors and witnesses of the marriage stating therein the exact place and date of marriage, the facts and
circumstances surrounding the marriage and the reason or cause of the delay.
(b) Certified copy of the application for marriage license bearing the date when the marriage license was issued, whenever
applicable.
(c) Birth Certificate (not late registered) of at least two (2) children (if applicable) issued by PSA or LCR indicating clearly
the date and place of marriage of parents; and
(d) Certified True copy of the church or civil marriage certificate duly signed and sealed by the parish priest, minister, or
custodian of said records.
4. For Muslim Claimants: Late-registered Birth/Death/Marriage Certificates shall be supported with (a) Certificate issued by
the Muslim Circuit Registrar concerned; and (b) in the absence of such, Sworn Statements of your Municipal Mayor, the
Commanding Officer/ Commander-in-arms of the veteran and of two (2) disinterested persons who have personal knowledge
of the facts of birth/death/marriage will do.
5. For Indigenous People: Late-registered Birth/Death/Marriage Certificates shall be supported with (a) Certification duly-
issued by the National Commission for Indigenous People (NCIP), or any evidentiary documents from their respective
chieftains that will prove their fact of Birth.
6. Submit the accomplished application forms with the required documents to PVAO or to any PVAO Field Service Extension
Office where it will be assigned a claim number. A duplicate copy, properly marked with the assigned claim number, will be
returned to you as your proof of filing; and
7. Do not pay any amount to any person in connection with the filing of this application.
Issued by :
Date :
