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HQP-HLF-001 Application for Housing Loan Restructuring/Penalty Condonation Program
Pag - Ibig application form for housing loan restructuring/ penalty condonation
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APPLICATION FOR LOAN RESTRUCTURING/
PENALTY CONDONATION
APPLICATION NO.
DATE FILED
TIME
(Under R.A. 9679)
PRINCIPAL BORROWER’S DATA
LAST NAME
FIRST NAME
NAME EXTENSION
MIDDLE NAME
(e.g. Jr., II)
MAIDEN NAME
DATE OF BIRTH
HL ACCOUNT NO.
(for married women only)
Pag-IBIG MID NO.
PERMANENT HOME ADDRESS
House/Bldg/Unit/Floor/Room No.
Lot No.
Building
ZIP Code
MARITAL STATUS
Single/Unmarried
Married
Widow/er
Legally Separated
Annulled
m
d
d
y
y
y
y
GENDER
MALE
FEMALE
Barangay
Municipality/City/Province
Phase No.
Street
Subdivision
Block No.
m
MEMBERSHIP
CATEGORY
PRESENT ADDRESS
House/Bldg/Unit/Floor/Room No.
Lot No.
Building
Block No.
Phase No.
Street
Subdivision
TAXPAYERS IDENTIFICATION
NUMBER (TIN)
Barangay
SSS/GSIS ID NUMBER
MANDATORY
Employed Private
Employed Government
Employed Private
Household
Overseas Filipino Worker
Self-Employed (SE)
Other Working Group
(OWG)
State/Country (If abroad)
(Indicate country code if abroad)
COUNTRY + AREA CODE TELEPHONE NO.
HOME TEL. NO.
BUSINESS TEL NO.
VOLUNTARY
Employed
Individual Payor (IP)
Other Working Group
(OWG, if income is less than
P1,000.00)
EMPLOYER/BUSINESS NAME (if self-employed)
CONTACT NUMBER/S
NET MONTHLY INCOME
Municipality/City/Province
ZIP Code
CELLPHONE NO.
E-MAIL ADDRESS
PREFERRED MAILING ADDRESS
Permanent Home Address
Present Address
Employer/Business Address
EMPLOYER/BUSINESS ADDRESS
LEGAL HEIR’S DATA
LAST NAME
FIRST NAME
NAME EXTENSION
MIDDLE NAME
(e.g. Jr., II)
MAIDEN NAME
PERMANENT HOME ADDRESS
House/Bldg/Unit/Floor/Room No.
Pag-IBIG MID NO.
Lot No.
DATE OF BIRTH
Block No.
Street
Subdivision
Barangay
Municipality/City/Province
ZIP Code
Building
Street
Subdivision
Barangay
Municipality/City/Province
ZIP Code
State/Country (If abroad)
EMPLOYER/BUSINESS NAME (if self-employed)
EMPLOYER/BUSINESS ADDRESS
m
d
d
y
y
MARITAL STATUS
Single/Unmarried
Married
Widow/er
Legally Separated
Annulled
PRESENT ADDRESS
Lot No.
Block No.
Attach Here
1” x 1”
ID PHOTO
Phase No.
m
Building
House/Bldg/Unit/Floor/Room No.
GENDER
MALE
FEMALE
(for married women only)
Phase No.
MEMBERSHIP
CATEGORY
MANDATORY
Employed Private
Employed Government
Employed Private
Household
Overseas Filipino Worker
Self-Employed (SE)
Other Working Group
(OWG)
VOLUNTARY
Employed
Individual Payor (IP)
Other Working Group
(OWG, if income is less than
P1,000.00)
NET MONTHLY INCOME
THIS FORM MAY BE REPRODUCED. NOT FOR SALE.
y
y
TAXPAYERS IDENTIFICATION
NUMBER (TIN)
SSS/GSIS ID NUMBER
CONTACT NUMBER/S
(Indicate country code if abroad)
COUNTRY + AREA CODE TELEPHONE NO.
HOME TEL. NO.
BUSINESS TEL NO.
CELLPHONE NO.
E-MAIL ADDRESS
PREFERRED MAILING ADDRESS
Permanent Home Address
Present Address
Employer/Business Address
(Revised/December 2011)
CO-BORROWER’S DATA (1)
LAST NAME
FIRST NAME
NAME EXTENSION
MIDDLE NAME
(e.g. Jr., II)
MAIDEN NAME
HL ACCOUNT NO.
GENDER
MALE
FEMALE
(for married women only)
Pag-IBIG MID NO.
PERMANENT HOME ADDRESS
House/Bldg/Unit/Floor/Room No.
Lot No.
DATE OF BIRTH
Block No.
Phase No.
m
Building
Attach Here
1” x 1”
ID PHOTO
m
d
d
y
y
y
y
RELATION TO PRINCIPAL BORROWER
Street
SPOUSE
SON/DAUGHTER
Subdivision
Barangay
Municipality/City/Province
ZIP Code
PARENT
NONE
OTHERS(please specify)
_______________
MARITAL STATUS
Single/Unmarried
Married
Widow/er
Legally Separated
Annulled
TAXPAYERS IDENTIFICATION
NUMBER (TIN)
MEMBERSHIP
CATEGORY
CONTACT NUMBER/S
SSS/GSIS ID NUMBER
PRESENT ADDRESS
House/Bldg/Unit/Floor/Room No.
Lot No.
Building
(Indicate country code if abroad)
COUNTRY + AREA CODE TELEPHONE NO.
MANDATORY
Employed Private
Employed Government
Employed Private Household
Overseas Filipino Worker
Self-Employed (SE)
Other Working Group (OWG)
Barangay
Municipality/City/Province
Phase No.
Street
Subdivision
Block No.
ZIP Code
HOME TEL. NO.
BUSINESS TEL NO.
CELLPHONE NO.
VOLUNTARY
Employed
Individual Payor (IP)
Other Working Group (OWG,
if income is less than P1,000.00)
State/Country (If abroad)
E-MAIL ADDRESS
PREFERRED MAILING ADDRESS
Permanent Home Address
Present Address
Employer/Business Address
EMPLOYER/BUSINESS NAME (if self-employed)
NET MONTHLY INCOME
EMPLOYER/BUSINESS ADDRESS
CO-BORROWER’S DATA (2)
LAST NAME
FIRST NAME
NAME EXTENSION
MIDDLE NAME
(e.g. Jr., II)
MAIDEN NAME
HL ACCOUNT NO.
GENDER
MALE
FEMALE
(for married women only)
Pag-IBIG MID NO.
PERMANENT HOME ADDRESS
House/Bldg/Unit/Floor/Room No.
Lot No.
DATE OF BIRTH
Block No.
Phase No.
m
Building
Attach Here
1” x 1”
ID PHOTO
m
d
d
y
y
y
y
RELATION TO PRINCIPAL BORROWER
Street
SPOUSE
SON/DAUGHTER
Subdivision
Barangay
Municipality/City/Province
ZIP Code
PARENT
NONE
OTHERS(please specify)
_______________
MARITAL STATUS
Single/Unmarried
Married
Widow/er
Legally Separated
Annulled
TAXPAYERS IDENTIFICATION
NUMBER (TIN)
MEMBERSHIP
CATEGORY
CONTACT NUMBER/S
SSS/GSIS ID NUMBER
PRESENT ADDRESS
House/Bldg/Unit/Floor/Room No.
Lot No.
Building
(Indicate country code if abroad)
COUNTRY + AREA CODE TELEPHONE NO.
MANDATORY
Employed Private
Employed Government
Employed Private Household
Overseas Filipino Worker
Self-Employed (SE)
Other Working Group (OWG)
Barangay
Municipality/City/Province
Phase No.
Street
Subdivision
Block No.
ZIP Code
HOME TEL. NO.
BUSINESS TEL NO.
CELLPHONE NO.
VOLUNTARY
Employed
Individual Payor (IP)
Other Working Group (OWG,
if income is less than P1,000.00)
State/Country (If abroad)
EMPLOYER/BUSINESS NAME (if self-employed)
NET MONTHLY INCOME
EMPLOYER/BUSINESS ADDRESS
E-MAIL ADDRESS
PREFERRED MAILING ADDRESS
Permanent Home Address
Present Address
Employer/Business Address
CERTIFICATION
I/WE HEREBY CERTIFY THAT THE INFORMATION AND ALL STATEMENTS MADE HEREIN GIVEN ARE TRUE AND CORRECT TO THE BEST OF
MY/OUR KNOWLEDGE AND BELIEF. I/WE FURTHER CERTIFY THAT MY/OUR SIGNATURE APPEARING HEREIN IS/ARE GENUINE AND AUTHENTIC.
IN CASE OF FALSIFICATION, MISREPRESENTATION, OR ANY OTHER SIMILAR ACTS COMMITTED BY ME/US, HDMF SHALL AUTOMATICALLY
REJECT OR CANCEL MY/OUR APPLICATION FOR LOAN RESTRUCTURING.
___________________________________
PRINCIPAL BORROWER’S SIGNATURE
OVER PRINTED NAME
____________
DATE
_____________________________________
CO-BORROWER’S (1)
SIGNATURE OVER PRINTED NAME
_____________
DATE
_____________________________________
CO-BORROWER’S (2)
SIGNATURE OVER PRINTED NAME
_____________
DATE
