FLH060-6

APPLICATION FOR HOME REHABILITATION LOAN

(Please accomplish in three (3) copies)

Pag-IBIG MID No.

Desired Loan Amount Application No
Loan Term (Years) HL Account No.

BORROWER’S DATA
Last Name First Name Name Extension Middle Name No Middle Name
(Check if applicable only)


ATTACH HERE
1” x 1”
Mother’s Maiden Name No Middle Name Gender
(Check if applicable) ID PHOTO
Last Name First Name Middle Name


Male
Female OF APPLICANT

Date of Birth (mm/dd/yyyy) TIN EE SSS/GSIS No. Civil Status Citizenship

Single
Annulled

Married
Legally
Cellphone No.

Widow/er Separated

Permanent Home Address Lot No. Block No. Phase No. Building Street
House/Bldg/Unit/Floor/Room No.

Subdivision/District Barangay Municipality/City/Province Zip Code

Present Address Lot No. Block No. Phase No. Building Street
House/Bldg/Unit/Floor/Room No.

Subdivision/District Barangay Municipality/City/Province Zip Code

Employer/Business Name (If self-employed) Years In Employment/Business Business Tel. No.

Employer/Business Address

Preferred Mailing Address Email Address Tel. No.

Permanent Home Address
Present Address
Employer’s/Business Address

SPOUSE PERSONAL DATA

Last Name First Name Name Extension Middle Name No Middle Name Date of Birth (mm/dd/yyyy)
(Check if applicable only)


Employer/Business Name (If self-employed) Employer/Business Address TIN

COLLATERAL
Property Location Address Lot No. Block No. Phase No. Building Street
House/Bldg/Unit/Floor/Room No.

Subdivision/District Barangay Municipality/City/Province Zip Code

Name of Developer/Registered Owner TCT/CCT No. Tax Declaration No.

REAL ESTATE OWNED

TYPE OF ACQUISITION
LOCATION TCT NO. MARKET VALUE
PROPERTY COST
 OUTSTANDING CREDIT LINE/LOAN AVAILMENTS
Creditor & Address Collateral Type Maturity Date

Amount/Balance Mo. Amortization

Creditor & Address Collateral Type Maturity Date

Amount/Balance Mo. Amortization

Creditor & Address Collateral Type Maturity Date

Amount/Balance Mo. Amortization

CHARACTER REFERENCES
NAME ADDRESS TEL.NO.

MISCELLANEOUS (Answer the following questions with YES or NO, If YES, please elaborate on the details as required.)

Yes
No
Have you been ever been formally charged?
If yes, give details
Are there past or pending cases against you?
Yes
No
Have you ever been guilty of administrative offense?
Yes
No
If yes, give details
Have you been ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?
Yes
No
If yes, give details
CERTIFICATION

I/We certify that the foregoing information/statement are to the best of my/our knowledge, true, correct, and complete, And I/We hereby agree on the
following:
1. That any misrepresentation of a material fact is a ground for disapproval of the application or foreclosure of the mortgage as the case may be;
2. To notify Pag-IBIG Fund of any material change affecting the information contained herein;
3. That all information obtained by Pag-IBIG Fund shall remain its property whether or not the loan is granted; and
4. To pay Pag-IBIG Fund the non-refundable sum of One Thousand Pesos (P1,000.00) as processing/filing fee to be paid upon filing of the loan
application.
I further certify that the signature/s appearing below is/are genuine.

_______________________________________________ ___________________________________________
SIGNATURE OF BORROWER OVER PRINTED NAME SIGNATURE OF SPOUSE OVER PRINTED NAME

____________________________________ ____________________________________
DATE DATE
FOR HDMF USE ONLY
RECEIVED BY SIGNATURE OF Pag-IBIG FUND REPRESENTATIVE NAME IN PRINT DATE RECEIVED

THIS FORM MAY BE REPRODUCED. NOT FOR SALE.