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    Members Record Form

    Uploaded by

    ELLA
    ks

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Members Record Form

    Uploaded by

    ELLA
    2 views2 pages
    ks

    Original Title

    members_record_form

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    ks

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2 views2 pages

    Members Record Form

    Uploaded by

    ELLA
    ks

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    PERAA SSS No.

    ATTACH PERAA ID NUMBER


    MEMBER’S (For PERAA use only)
    1X1
    RECORD (MR) LATEST PHOTO TIN
    PLS. READ INSTRUCTIONS AT PRINTED NAME
    THE BACK BEFORE FILLING UP AT THE BACK
    THE FORM
    Surname Given Name Middle Name
    Sex M F

    Civil Status S M W Sep


    Date of Birth Mo. Day Year Place of Birth Tel. No.
    Mobile No.
    Email Address
    Permanent Mailing Address (No. & Street, City/Town/Province)

    BENEFICIARIES
    Date of Birth Relationship to You Revocable Irrevocable
    PRIMARY Mo. Day Year

    CONTINGENT

    In case of minor beneficiary/ies (ages below 18), please Name of Guardian


    assign a guardian who should be over 18 years of age.
    X Relationship to minor
    TO BE FILLED OUT BY EMPLOYER

    Present Employer: Name


    (Institution) Address Tel. No.

    Date of Employment Date of PERAA Coverage Status of Employment Position/Title (Specify)


    Mo. Day Year Mo. Day Year
    Full time 1. Academic
    Part time 2. Non-Academic

    Previous PERAA-ID No. Basic Salary Certified Correct By: (Signature over printed name)

    P
    none Name Position
    cannot remember (For School’s Authorized Signatory only)

    I hereby certify that all information above are Member’s Thumbmark (FOR PERAA USE ONLY)
    true and correct and that I bind myself to all the
    provisions of PERAA Plan Resolution and other
    related documents. LEFT
    Thumbmark DATE RECEIVED:

    Signature Over Printed Name


    RIGHT By:
    Thumbmark
    Date Accomplished
    The Member’s Record (MR)

    1. Employees should first be eligible for membership (under Retirement Plan


    Resolution - RPR) and must be covered in the Premium Remittance List before
    they are required to accomplish this form in duplicate (one for PERAA file and one
    for employee).

    2. The MR is the member’s permanent record in PERAA under his present employer.
    In case of transfer to another Participating Institution, the member, upon coverage,
    should accomplish a new MR.

    3. The MR is the basis for the issuance of membership ID card.

    4. The MR is a requisite for the processing of the member’s benefit claims. Please
    note that failure to submit this form may result in the disqualification of the
    member’s beneficiaries from the Minimum Death Benefit (MDB) grant.

    5. Primary Beneficiaries shall have the prior claim on the benefits accruing for
    member’s account. If no Primary Beneficiary is living, the benefits go to the
    member’s Contingent Beneficiary.

    6. The member may change beneficiaries at any time unless the beneficiary is
    irrevocable. Irrevocable beneficiaries can be changed only if the member will file
    a notarized affidavit of consent by the said beneficiary.

    Private Education Retirement Annuity Association


    Attn.: Member Services Department
    16th Floor Multinational Bancorporation Centre
    6805 Ayala Avenue, Salcedo Village, Makati City 1227
    P.O. Box 1785 MCPO, 1257 Makati City
    Tel. No. 817-4531 • Fax No. 818-7921, 889-9884
    E-mail: memberservices@peraa.org, peraa@peraa.org

    MSD Form
    6th Revision August 2011

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