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

WITH ADDITIONAL LOAN?

Pag-IBIG MID No./RTN

Yes
No
DESIRED RE-PRICING PERIOD (in years)

3

5

10

15

IF WITH ADDITIONAL LOAN, RE-PRICING SHALL BE

APPLIED ON?

AVAILED OF RESTRUCTURING?

WITH PDC

Original Loan only

Additional Loan only

Yes
No

WITHOUT PDC

MODE OF PAYMENT

Salary Deduction

Over-the-Counter

Cash/Check

Post-Dated Checks

PROPERTY LOCATION
Unit/Room No., Floor

Building Name

Subdivision

Lot No., Blk No., Phase No., House No.

Barangay

Municipality/City

Street Name

Province and State Country (if abroad)

Both loans

Collecting Agent

Bank

Developer

Remittance
Center

BORROWERS DATA
LAST NAME

FIRST NAME

NAME EXTENSION

CITIZENSHIP

MIDDLE NAME

DATE OF BIRTH (mm/dd/yy)

SEX

M
F
MARITAL STATUS

PERMANENT HOME ADDRESS

Unit/Room No., Floor

Building Name

Subdivision

Barangay

Lot No., Blk No., Phase No., House No.

Municipality/City

Street Name

Province and State Country (if abroad)

Zip Code

Single/

Legally

Unmarried

Married

Widow/er

Annulled

Separated

CONTACT DETAILS (Indicate country code if

abroad)
COUNTRY + AREA CODE TELEPHONE NO.

PRESENT HOME ADDRESS

Unit/Room No., Floor

Home

Building Name

Subdivision
abroad)

Lot No., Block No., Phase No., House No.

Barangay

Municipality/City

Street Name

Province and State Country (if

Zip Code

Cell Phone
Email Address

HOME OWNERSHIP

Owned

Company
Living w/ relatives/parents

Mortgaged
Rented at P__________/mo.
EMPLOYER/BUSINESS NAME (If self-employed)

YEARS OF STAY IN PRESENT

HOME ADDRESS

EE SSS/GSIS ID No.
CONTACT DETAILS (Indicate country code if
abroad)

TIN

COUNTRY + AREA CODE TELEPHONE NO.

Business (Direct Line)

EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor

Building Name

Subdivision

Lot No., Block No., Phase No., House No

Barangay

Municipality/City

Street Name.

Province and State Country (if abroad)

OCCUPATION

Employed

Self-Employed

Business (Trunk Line)

Zip Code

Employer/Business Email Address

INDUSTRY
 Accounting
 Activities of Private Households as
Employers & Undifferentiated
Production Activities of Private
Households
 Agriculture, Hunting, Forestry &
Fishing
 Basic Materials

 Construction
 Education & Training
 Electricity, Gas and Water Supply
 Extra-Territorial Organization & Bodies
 Financial Services/ Intermediation
 HR/Recruitment
 Health and Social Work;
Health and Medical Services

 Life Sciences
 Management
 Manufacturing
 Media
 Mining and Quarrying
 Other Community, Social & Personal Service
Activities

 Public Administration & Defense;

Compulsory Social Security
 Technology
 Transport, Storage and Communications
 Travel and Leisure
 Wholesale & Retail Trade; Repair of Motor
Vehicles, Motorcycles, Personal &
Household Goods

SPOUSES PERSONAL DATA

LAST NAME

FIRST NAME

NAME EXTENSION

MIDDLE NAME

CITIZENSHIP

DATE OF BIRTH (mm/dd/yy)

EMPLOYER/BUSINESS NAME (If self-employed)

YEARS IN EMPLOYMENT/
BUSINESS

EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor

Building Name

Subdivision

Barangay

INDUSTRY
 Accounting
 Activities of Private Households as
Employers & Undifferentiated
Production Activities of Private
Households
 Agriculture, Hunting, Forestry &
Fishing
 Basic Materials

TIN

Lot No., Block No., Phase No., House No.

Municipality/City

Street Name

OCCUPATION

Employed

Self-Employed

Province and State Country (if abroad)

 Construction
 Education & Training
 Electricity, Gas and Water Supply
 Extra-Territorial Organization & Bodies
 Financial Services/ Intermediation
 HR/Recruitment
 Health and Social Work;
Health and Medical Services

 Life Sciences
 Management
 Manufacturing
 Media
 Mining and Quarrying
 Other Community, Social & Personal
Service Activities
Public Administration & Defense;
Compulsory Social Security

Zip Code

POSITION & DEPARTMENT

BUSINESS TEL. NO.

 Technology
 Transport, Storage and Communications
 Travel and Leisure
 Wholesale & Retail Trade; Repair of Motor
Vehicles, Motorcycles, Personal &
Household Goods

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)
BANK

TYPE OF
ACCOUNT

BRANCH/ADDRESS

ACCOUNT NO.

DATE OPENED

AVE. BALANCE

CREDIT CARDS OWNED

(August 2012)

(Indicate your 3 most active)

CARD TYPE
(e.g. Visa/Mastercard)

ISSUER NAME

CARD EXPIRY
(mm/yyyy)

CREDIT LIMIT

REAL ESTATE OWNED

TYPE OF
PROPERTY

LOCATION

ACQUISITION
COST

TCT NO.

MARKET VALUE

MORTGAGE
BALANCE

RENTAL INCOME

OUTSTANDING CREDITS/LOAN AVAILMENTS

Creditor & Address

Security

Creditor & Address

Security

Creditor & Address

Security

Type

Maturity Date

Amount/Balance

Mo. Amortization

Type

Maturity Date

Amount/Balance

Mo. Amortization

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

REPT RECEIPT

UPDATED

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

WITH FINDINGS

UPDATED

ACCOUNT TAKEN OUT UNDER CIRCULAR 247?

YES

TAKE-OUT DATE ________________

NOT UPDATED

UPDATED

IN ARREARS

FOR CIRCULAR 300, WITH PERFECT REPAYMENT HISTORY?

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

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

LOAN AMOUNT

APPLICABLE LTA RATIO UNDER CIRCULAR 310

BES RESULT

VERIFIED BY

REVIEWED BY

DATE

ADJUSTED LTA RATIO BASED ON BES RESULT

DATE

REMARKS

THIS FORM CAN BE REPRODUCED. NOT FOR SALE.