Request for Financial Assistance

________________
(Date accomplished)

I,

________________________,

single/married,

employed

in

this

Commission as (Position) _______________________ of (Department/Office)

____________________________________, and a member of the Provident
Fund, hereby request for financial assistance; and certify that I suffered
damage/injury, due to sickness and was hospitalized. That the injury/disability is not
due to intoxication or habitual drunkenness, wilful intention to injure or kill, notorious
negligence, vicious or immoral habit, or use of prohibited drugs; and that the
document submitted in support hereof are true and correct.
IN WITNESS HEREOF, I hereunto affixed my signature this _____ day of
___________, 2014 at __________________, Philippines.

____________________
(Signature above printed name )

SUBSCRIBED AND SWORN TO before me this __________ day of

______________, 2014 at __________________, Philippines.

Notary Public