HQP-SLF-065

MULTI-PURPOSE LOAN (MPL) (V06, 08/2021)

APPLICATION FORM Pag-IBIG MID NO./RTN APPLICATION NO.
(To be filled out by applicant. Print this form back to back on one single sheet of paper)
Type or Print Entries 1460-0030-6776
LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME MAIDEN MIDDLE NAME NO MIDDLE NAME DATE OF BIRTH PLACE OF BIRTH
(e.g., Jr., II) (for married women) (check if applicable only) General Luna Quezon
TIÑA ARNEL BALANE  03/17/1965
COMPLETE MOTHER’S MAIDEN NAME (Required) NATIONALITY SEX MARITAL STATUS CITIZENSHIP EMAIL ADDRESS
 Male  Single  Widow/er  Annulled
BALANE, ADELAIDA DIONCO FILIPINO  Female  Married  Legally Separated FILIPINO [email protected]
PRESENT HOME ADDRESS (Required) Unit/ Room No., Floor Building Name Lot No., Block No., Phase No. House No. CELL PHONE NUMBER (Required) HOME TELEPHONE NUMBER
09167014554 N/A
Street Name Subdivision Barangay Municipality/City Province/State/Country (if abroad) ZIP Code APPLICANT’S TAXPAYER SSS/GSIS NO.
SITIO IDENTIFICATION NUMBER (TIN)
KAPIHAN BATAAN LUCBAN QUEZON 4328 913-842-243 04-3476750-8
PERMANENT HOME ADDRESS (Required) Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No. BUSINESS TELEPHONE NUMBER NATURE OF WORK
63(042)540 1491 Gardener
Street Name Subdivision Barangay Municipality/City Province/State/Country (if abroad) ZIP Code LOAN TERM DESIRED LOAN AMOUNT
QUEZON 4328  Two (2) Years  Three (3) Years
SITIO KAPIHAN BATAAN LUCBAN
EMPLOYER/BUSINESS NAME LOAN PURPOSE
INSULAR BOTANICAL INTERNATIONAL INC Non-Housing Related
 Vacation/travel
 Livelihood/additional capital in small
EMPLOYER/BUSINESS ADDRESS Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No. Street Name  Special events
business
 Car repair
131 LUCBAN-SAMPALOC ROAD  Tuition/Educational Expenses
 Health & wellness
Subdivision Barangay Municipality/City Province/State/Country (if abroad) ZIP Code  Payment of utility/credit card bills
 Purchase of appliance &
BRGY KILIB LUCBAN QUEZON 4328 furniture/electronic gadgets
 Others, specify
Housing Related
EMPLOYEE ID NUMBER DATE OF EMPLOYMENT SOURCE OF FUND ______________
 Minor home improvement/home
IBII-2010 11/2004 Employment Income renovation/ upgrades
PREVIOUS EMPLOYMENT DETAILS FROM DATE OF Pag-IBIG MEMBERSHIP (Use another sheet if necessary)
EMPLOYER/BUSINESS NAME EMPLOYER/BUSINESS ADDRESS FROM (mm/yy) TO (mm/yy)
INSULAR BOTANICAL INTERNATIONAL INC 131 LUCBAN-SAMPALOC ROAD BRGY. KILIB LUCBAN, QUEZON 11/2004 10/2023

SIGNATURE OF APPLICANT PAYROLL ACCOUNT/DISBURSEMENT CARD

In the event of the approval of my application for Multi-Purpose Loan, I hereby authorize 5293-5391-2743-8654
Pag-IBIG Fund to credit my loan proceeds through my Payroll Account/Disbursement Card that
NAME OF BANK/BRANCH
I have indicated on the right portion.
PHILIPPINE NATIONAL BANK (PNB)

APPLICATION AGREEMENT
In consideration of the loan that may be granted by virtue of this application subject to the pertinent provisions of the Implementing Rules This office agrees to collect the corresponding monthly
and Regulations of Pag-IBIG Fund, I hereby waive my rights under R.A. No. 1405 (Secrecy of Bank Deposits Act) and authorize amortization on this loan and the MS of herein applicant
Pag-IBIG Fund to verify/validate my payroll account/disbursement card. Furthermore, I hereby authorize my present employer, through salary deduction, together with the employer
Insular Botanical International Inc
____________________________________________________________________ or any employer with whom I may get employed counterpart, and remit said amounts to Pag-IBIG Fund on or
in the future, to deduct the membership savings (MS) and monthly amortization due from my salary and remit the same to Pag-IBIG before the 15th day of each month, for the duration that the loan
Fund. If the resulting monthly net take home pay after deducting the computed monthly amortization on MPL falls below the monthly net remains outstanding. However, should we deduct the monthly
take home pay as required under the GAA/company policy, I authorize Pag-IBIG Fund to compute for a lower loanable amount. amortization due from the applicant’s salary but failed to remit
I understand that should I fail to pay the monthly amortization due, I shall be charged with a penalty of 1/20 of 1% of any unpaid amount it on due date, this office agrees to pay the corresponding
for every day of delay. penalty charged to applicant equivalent to 1/20 of 1% of any
unpaid amount for every day of delay and penalty for non-
If for any reason excess loan proceeds are erroneously credited to my payroll account/disbursement card, I hereby authorize Pag-IBIG
Fund to debit/deduct the excess amount from my account without need of further notice of demand. Should my account balance be remittance equivalent to 1/10 of 1% per day of delay of the
insufficient, the Fund has the right to demand for the excess amount to be refunded. amount payable from the date the loan amortization or
payments fall due until paid.
I authorize Pag-IBIG Fund to disclose, submit, share or exchange any of my account information to legal and government regulating
agencies, other banks, partner-merchants or third party in accordance with R.A. No. 9510 (Credit Information System Act), R.A. No.
10173 (Data Privacy Act of 2012), and other related or pertinent laws and regulations, as described in Pag-IBIG Fund’s Freedom of
Information (FOI) Manual. The credit information may also be transferred to service providers (e.g., Credit Information Corporation,
ALEXANDER A. ELIAS
_________________________________________
Bankers Association of the Philippines - Credit Bureau), likewise in accordance with laws and regulations. HEAD OF OFFICE OR AUTHORIZED SIGNATORY
(Signature Over Printed Name)
Furthermore, I have read, understood and agree to be bound by the terms and conditions governing the
eDisbursement Facility/Program and Pag-IBIG Fund’s partner-banks’ internal guidelines. Gen. Manager
_________________________________________
I certify that the information given and any or all statements made herein are true and correct to the best of my knowledge and belief. I DESIGNATION
hereby certify under pain of perjury that my signature appearing herein is genuine and authentic.
201645010004
______________ _______________ 46
______________
ARNEL B. TIÑA
___________________________________ Pag-IBIG AGENCY CODE BRANCH CODE
Signature of Applicant Over Printed Name EMPLOYER ID NO.
PROMISSORY NOTE
For value received, I promise to pay on due date without need of demand to the order of 5. I shall be considered in default in any of the following cases:
Pag-IBIG Fund with principal office at Petron MegaPlaza, 358, Sen. Gil Puyat Avenue., City a. Any willful misrepresentation in any of the documents executed in relation hereto;
of Makati the sum of Pesos: b. Failure to pay any three (3) consecutive monthly amortizations;
c. Failure to pay any three (3) consecutive membership savings;
(P_______________) Philippine Currency, with an interest at the rate of 10.5% per annum d. Violation of any of the membership/STL/housing loan policies, rules, regulations, and
(equivalent rate of 17.50% based on diminishing principal balance), with interest during the guidelines of the Pag-IBIG Fund.
grace period and shall be amortized equally over the term of the loan. 6. In the event of default, the outstanding loan obligation shall become due and shall be
deducted from the Total Accumulated Value (TAV) after exerting all collection efforts.
I hereby waive notice of demand for payment and agree that any legal action, which may However, immediate offsetting of my outstanding loan obligation may be effected
arise in relation to this note, may be instituted in the proper court of Makati City. immediately upon approval of my request, provided such request is based on the
Finally, this note shall likewise be subject to the following terms and conditions: following justifiable reasons and upon validation by the Fund: Total disability or
1. I shall pay the amount of Pesos: _______________________________ insanity; Separation from service by reason of health; Death of member’s
(P_______________) through salary deduction, whenever feasible, over a period of immediate family member; Distressed member due to unemployment limited to
two (2) years or three (3) years, with a grace period of 2 months. In case I am unable layoff and/or closure of company; Critical illness of the member or any of his/her
to pay through salary deductions for any of the following circumstances, such immediate family member, as certified by a licensed physician under one of the
as but not limited to, suspension from work; leave of absence without pay; following categories, subject to the approval of the DCEO-Member Services
insufficiency of take home pay at any time during the term of the loan; or other Cluster: cancer, organ failure, heart-related illness, stroke and neuromuscular-
circumstances analogous to the foregoing, payments should be made directly to related illness; Repatriation of OFW member from host country and other
the Pag-IBIG Fund office where the loan was released. meritorious grounds as may be approved for by the Board, by reason thereof,
th
2. Payments are due on or before the 15 day of the month starting on resulted in his failure to pay the required amortization when due.
_________________________. 7. In the event of membership termination prior to loan maturity, any outstanding loan
3. Payments shall be applied according to the following order of priorities: Penalties, obligation, shall be deducted from my TAV and/or any amount due me or my
Interest and Principal. beneficiaries in the possession of the Fund. In case of my death, the outstanding
4. A penalty of 1/20 of 1% of any unpaid amount shall be charged to me for every day of obligation shall be computed up to the date of death. Any payment received after date
delay. of death shall be refunded to my beneficiaries.
Signed in the presence of: 8. In case of falsification, misrepresentation or any similar acts committed by me,
Pag-IBIG Fund shall automatically suspend my loan privileges indefinitely. I shall abide
RENASO ARQUIZA with all the applicable rules and regulations governing this lending program that
ROLANDO CONSTANTINO
________________________________ ________________________________ Pag-IBIG Fund may promulgate from time to time.
Witness Witness
(Signature Over Printed Name) (Signature Over Printed Name) ARNEL B. TIÑA
__________________________________
Signature of Applicant Over Printed Name
AUTHORITY TO DEDUCT (Optional)
In case of retirement/separation from employment, I hereby authorize my employer to deduct any outstanding MPL balance from my retirement SIGNATURE OF APPLICANT
or separation benefits to fully settle my loan obligation. In the event that my retirement/separation benefits are not sufficient to settle the outstanding
balance of my MPL or my employer fails for whatever reason, to deduct the same from said retirement/separation benefits, I hereby authorize
Pag-IBIG Fund to apply whatever benefits are due me from the Fund to settle the said obligation.
THIS PORTION IS FOR Pag-IBIG FUND USE ONLY
RECEIVED BY: APPROVED/DISAPPROVED BY:

(SIGNATURE OVER PRINTED NAME) _____________ (SIGNATURE OVER PRINTED NAME) _____________
(POSITION/DESIGNATION) DATE (POSITION/DESIGNATION) DATE
THIS FORM CAN BE REPRODUCED. NOT FOR SALE