HQP-HLF-182

APPLICATION FOR CONVERSION

TO FULL RISK-BASED PRICING MODEL
(PRINT ALL ENTRIES IN BLOCK OR CAPITAL LETTERS.)

LOAN PARTICULARS
HL ACCOUNT NUMBER Pag-IBIG MID No./RTN WITH ADDITIONAL LOAN? IF WITH ADDITIONAL LOAN, RE-PRICING SHALL BE

Yes
No APPLIED ON?
AVAILED OF RESTRUCTURING?
Original Loan only
Both loans
DESIRED RE-PRICING PERIOD (in years)

WITH PDC
WITHOUT PDC
Yes
No
Additional Loan only

3
5
10
15
PROPERTY LOCATION MODE OF PAYMENT
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name
Salary Deduction
Collecting Agent

Over-the-Counter
Bank

Cash/Check
Developer
Subdivision Barangay Municipality/City Province and State Country (if abroad)

Post-Dated Checks
Remittance
Center

BORROWER’S DATA
LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME CITIZENSHIP DATE OF BIRTH (mm/dd/yy) SEX

M
F

PERMANENT HOME ADDRESS MARITAL STATUS

Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name
Single/
Legally
Unmarried Separated

Married
Annulled
Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code
Widow/er
CONTACT DETAILS (Indicate country code if
abroad)
COUNTRY + AREA CODE TELEPHONE NO.
PRESENT HOME ADDRESS Home
Unit/Room No., Floor Building Name Lot No., Block No., Phase No., House No. Street Name

Subdivision Barangay Municipality/City Province and State Country (if Zip Code
Cell Phone
abroad)
Email Address
HOME OWNERSHIP YEARS OF STAY IN PRESENT EE SSS/GSIS ID No.
HOME ADDRESS

Owned
Company
Living w/ relatives/parents

Mortgaged
Rented at P__________/mo. CONTACT DETAILS (Indicate country code if
EMPLOYER/BUSINESS NAME (If self-employed) TIN abroad)
COUNTRY + AREA CODE TELEPHONE NO.
Business (Direct Line)
EMPLOYER/BUSINESS ADDRESS OCCUPATION
Unit/Room No., Floor Building Name Lot No., Block No., Phase No., House No Street Name.
Employed Business (Trunk Line)

Self-Employed
Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code Employer/Business Email Address

INDUSTRY
 Accounting  Construction  Life Sciences  Public Administration & Defense;
 Activities of Private Households as  Education & Training  Management Compulsory Social Security
Employer’s & Undifferentiated  Electricity, Gas and Water Supply  Manufacturing  Technology
Production Activities of Private  Extra-Territorial Organization & Bodies  Media  Transport, Storage and Communications
Households  Financial Services/ Intermediation  Mining and Quarrying  Travel and Leisure
 Agriculture, Hunting, Forestry &  HR/Recruitment  Other Community, Social & Personal Service  Wholesale & Retail Trade; Repair of Motor
Fishing  Health and Social Work; Activities Vehicles, Motorcycles, Personal &
 Basic Materials Health and Medical Services Household Goods

SPOUSE’S PERSONAL DATA

LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME CITIZENSHIP DATE OF BIRTH (mm/dd/yy) TIN

EMPLOYER/BUSINESS NAME (If self-employed) YEARS IN EMPLOYMENT/

BUSINESS

EMPLOYER/BUSINESS ADDRESS OCCUPATION POSITION & DEPARTMENT

Unit/Room No., Floor Building Name Lot No., Block No., Phase No., House No. Street Name
Employed

Self-Employed
Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code BUSINESS TEL. NO.

INDUSTRY
 Accounting  Construction  Life Sciences  Technology
 Activities of Private Households as  Education & Training  Management  Transport, Storage and Communications
Employer’s & Undifferentiated  Electricity, Gas and Water Supply  Manufacturing  Travel and Leisure
Production Activities of Private  Extra-Territorial Organization & Bodies  Media  Wholesale & Retail Trade; Repair of Motor
Households  Financial Services/ Intermediation  Mining and Quarrying Vehicles, Motorcycles, Personal &
 Agriculture, Hunting, Forestry &  HR/Recruitment  Other Community, Social & Personal Household Goods
Fishing  Health and Social Work; Service Activities
 Basic Materials Health and Medical Services Public Administration & Defense;
Compulsory Social Security

GROSS MONTHLY INCOME

PARTICULARS PRINCIPAL BORROWER SPOUSE
BASIC MONTHLY COMPENSATION
COST OF LIVING ALLOWANCE
OTHER SOURCE/S
TOTAL

INCOME DOCUMENT/S SUBMITTED UPON LOAN APPLICATION: ________________________________________________________________________________________

(October 2012)
 BANK ACCOUNTS
(Indicate your 3 most active)
TYPE OF
BANK BRANCH/ADDRESS ACCOUNT NO. DATE OPENED AVE. BALANCE
ACCOUNT

CREDIT CARDS OWNED (August 2012)

(Indicate your 3 most active)
CARD TYPE CARD EXPIRY
ISSUER NAME CREDIT LIMIT
(e.g. Visa/Mastercard) (mm/yyyy)

REAL ESTATE OWNED

TYPE OF ACQUISITION MORTGAGE
LOCATION TCT NO. MARKET VALUE RENTAL INCOME
PROPERTY COST BALANCE

OUTSTANDING CREDITS/LOAN AVAILMENTS

Creditor & Address Security Type Maturity Date

Amount/Balance Mo. Amortization

Creditor & Address Security Type Maturity Date

Amount/Balance Mo. Amortization

Creditor & Address Security Type Maturity Date

Amount/Balance Mo. Amortization

CERTIFICATION

I/We hereby certify, under pain of perjury that the information given and any or all statements made herein are true and correct to the best of my
knowledge and belief and my/our signature/s appearing herein is/are genuine and authentic.;

In case of falsification, misrepresentation or any similar acts committed by me, Pag-IBIG Fund shall automatically disapprove my application and I/We
shall pay Pag-IBIG Fund the Housing Loan amortization due with corresponding penalties. I/We shall abide with all applicable rules and regulations
governing this moratorium that Pag-IBIG Fund may promulgate from time to time.

I/We further agree to pay Pag-IBIG Fund a non-refundable sum of One Thousand Pesos (P1,000.00) as processing fee to be paid upon filing of this
application. I/We understand that should my/our application be approved, notarial and all other fees pertaining to the re-pricing shall be for my/our account.

____________________________________ ____________________________________
SIGNATURE OF BORROWER SIGNATURE OF SPOUSE

____________________________________ ____________________________________
DATE DATE

FOR Pag-IBIG FUND USE ONLY

For Billing and Collection Department/Loans and Contributions Management and Recovery Division use only
REPT RECEIPT MEMBERSHIP STATUS HL ACCOUNT STATUS

UPDATED
WITH FINDINGS
UPDATED
NOT UPDATED
UPDATED
IN ARREARS

ACCOUNT TAKEN OUT UNDER CIRCULAR 247? FOR CIRCULAR 300, WITH PERFECT REPAYMENT HISTORY?

YES TAKE-OUT DATE ________________
NO
YES
NO

For accounts taken out under Circular 247 for less than one (1) year
OUTSTANDING BALANCE AS OF ______________ LOAN-TO-APPRAISED VALUE (LTA) RATIO REMARKS

VERIFIED BY DATE APPROVED/DISAPPROVED BY DATE

For Loans Evaluation Department/Housing Loans Division use only

LOAN AMOUNT APPRAISED VALUE LOAN-TO-APPRAISED VALUE (LTA) RATIO

APPLICABLE LTA RATIO UNDER CIRCULAR 310 BES RESULT ADJUSTED LTA RATIO BASED ON BES RESULT

VERIFIED BY DATE REVIEWED BY DATE REMARKS

THIS FORM CAN BE REPRODUCED. NOT FOR SALE.