Exhibit 1

Land Bank of the Philippines

MUTUAL AID BENEFIT PROGRAM / LOSS OF LIFE AND DISABILITY BENEFIT PLAN
APPLICATION FOR MEMBERSHIP / DESIGNATION OF DEPENDENTS/BENEFICIARIES

ID NO.: NAME OF EMPLOYEE (Last, First, M.I.): DEPARTMENT/UNIT: 1ST DAY OF LBP SERVICE:

CIVIL STATUS: [ ] Single [ ] Solo Parent APPOINTMENT STATUS: [ ] Permanent [ ] Temporary

[ ] Married [ ] Widow/Widower [ ] Co-terminus [ ] Directly-Hired Contractual
MUTUAL AID BENEFIT PROGRAM [ ] Initial [ ] Additional [ ] Substitution
If additional or substitution, existing no. of registered dependents (maximum of 7): ______
NAME OF QUALIFIED DEPENDENTS/
DEPENDENT / BENEFICIARY RELATIONSHIP DATE OF BIRTH REMARKS BENEFICIARIES
A. For single employee
- parents not over 60 years old
- unmarried brothers/sisters who are
less than 21 years old

B. For married employee

- legitimate spouse
- unmarried legitimate/legally adopted
children who are less than 21 years old

C. For widow/widower
- unmarried legitimate/legally adopted
children
- Parents not over 60 years old

LOSS OF LIFE AND DISABLITY BENEFIT PLAN [ ] Initial [ ] Additional [ ] Substitution

NAME OF QUALIFIED DEPENDENTS/
DEPENDENT / BENEFICIARY RELATIONSHIP DATE OF BIRTH REMARKS BENEFICIARIES
PRIMARY A. For single employee
- Primary – parents
- Secondary – brothers and sisters
- In the absence of the foregoing, other
persons designated by the employee

B. For solo parent

- Primary – children

C. For married employee

- Primary – legal spouse and children
- Secondary – parents
- In the absence of the foregoing, other
persons designated by the employee

D. For widow/widower
- Primary – children
- Secondary – parents
SECONDARY - In the absence of the foregoing, other
persons designated by the employee

OTHERS

CERTIFIED CORRECT: VALIDATED BY:

Signature of Employee/Date Head, Personnel Administration Dept. (PAD) Signature over Printed Name
NOTE:  Attach DULY CERTIFIED copy/ies of birth certificate/s and other legal documents showing name and date of birth of
beneficiaries if these have not been submitted to PAD.
 Misrepresentation and fraudulent information/documents shall be a ground for disciplinary action.
Distribution: 1 – PFO; 2 – PAD; 3 – Employee concerned