Pag Ibig 1
Pag Ibig 1
Pag Ibig 1
LATEST PHOTO
(1" x 1")
CIVIL STATUS
FEMALE DAY YEAR MO
BIRTHDATE
PLACE OF BIRTH
SINGLE MARRIED
FOR AFP EMP-SERIAL/ACCT. NO. FOR DECS EMP-DIV. CODE/ STATION CODE/EMPLOYEE NO.
EMPLOYER CATEGORY
PRIVATE GOVERNMENT
NAME OF SPOUSE
[IN CASE OF DEATH, FUND BENEFITS SHALL BE DIVIDED AMONG THE MEMBER'S LEGAL HEIRS IN ACCORDANCE WITH THE NEW CIVIL CODE AS AMENDED BY THE NEW FAMILY CODE] (Use another sheet if necessary)
NAME OF FATHER
NAME OF MOTHER
(IN CASE YOU DO NOT HAVE SPOUSE/CHILD/CHILDREN OR PARENTS, RELATIVES WITHIN SIXTH (6TH) CIVIL DEGREE OF CONSANGUINITY)
OTHER BENEFICIARIES
NAME
RELATIONSHIP
EMPLOYMENT HISTORY FROM DATE OF Pag-IBIG MEMBERSHIP (Use another sheet if necessary) ADDRESS NAME OF EMPLOYER
MEMBERSHIP CATEGORY
EMPLOYER CERTIFICATION
I HEREBY CERTIFY UNDER PAIN OF PERJURY THAT THE EMPLOYEE NAMED HEREIN IS EMPLOYED BY US AND IS A REGISTERED Pag-IBIG MEMBER WITH THE FOLLOWING RECORD: 1. EMPLOYMENT STATUS 2. SALARY BASIC COLA TOTAL PERMANENT TEMPORARY
I HEREBY CERTIFY THAT THE ABOVE DATA AND INFORMATION ARE TRUE AND CORRECT.
SIGNATURE OF MEMBER
DATE
AUTHORIZED SIGNATORY (Signature Over Printed Name) DESIGNATION EMPLOYER SSS ID No./GOV'T AGENCY CODE HDMF ID NO. PFR NO. LEFT THUMBMARK AMOUNT PERIOD COVERED RIGHT THUMBMARK VERIFIED BY/DATE
(Revised 5/2001)
HDMF M1-2
(Pls. read instructions at the back before accomplishing this form) NEW MEMBER - An employee/individual who is remitting his first Pag-IBIG contribution as of the date the MDF is being accomplished. 1 OLD MEMBER - An employee/individual is already a registered Pag-IBIG member at the time the MDF is being accomplished. TRANSFEREE - A registered Pag-IBIG member who remitted his contribution to another Pag-IBIG NCR Branch/Regional or Extension Office. FAMILY NAME FIRST NAME MIDDLE NAME 2 HOME ADDRESS 6 7
FOR DECS EMP-DIV. CODE/ STATION CODE/EMPLOYEE NO.
2 3
Put an X mark to indicate your Pag-IBIG Membership Classification Print your complete name This refers to the middle name of a married woman before marriage. Example : Before marriage: After marriage:
Family Name Santos Family Name Cruz First Name Evelyn Middle Name David
SEX
MALE
CIVIL
FEMALE SINGLE MARRIED
MO
DAY
HOME TEL. NO. YEAR 9 Pag-IBIG HOUSING LOAN ID NO. 15 WITH HOUSING LOAN 18 NO YES
HDMF ID NO. EMPLOYEE ID NO. SSS/GSIS ID NO. TAX IDENTIFICATION NO. (TIN) FOR AFP EMP-SERIAL/ACCT. NO. 10 COMPANY/EMPLOYER 11 16 19 12 13
14
EMPLOYER CATEGORY 17
PRIVATE
GOVERNMENT
COMPANY/EMPLOYER ADDRESS
BENEFICIARIES
NAME OF SPOUSE
[IN CASE OF DEATH, FUND BENEFITS SHALL BE DIVIDED AMONG THE MEMBER'S LEGAL HEIRS IN ACCORDANCE WITH THE NEW CIVIL CODE AS AMENDED BY THE NEW FAMILY CODE] (Use another sheet if necessary) 21 CHILDREN NAME BIRTHDATE 22 23 NAME OF
(IN CASE YOU DO NOT HAVE SPOUSE/CHILD/CHILDREN OR PARENTS, OTHER BENEFICIARIES RELATIVES WITHIN SIXTH (6TH) CIVIL DEGREE OF CONSANGUINITY)
NAME
RELATIONSHIP
24
25
26
27
EMPLOYMENT HISTORY FROM DATE OF Pag-IBIG MEMBERSHIP (Use another sheet if necessary)
NAME OF EMPLOYER ADDRESS MEMBERSHIP CATEGORY FROM (Mo./Yr.) TO (Mo./Yr.)
28
29
30
31
32
EMPLOYER CERTIFICATION
I HEREBY CERTIFY THAT THE EMPLOYEE NAMED HEREIN IS EMPLOYED BY US AND IS A REGISTERED Pag-IBIG MEMBER WITH THE FOLLOWING RECORD: 1. 2. EMPLOYMENT STATUS SALARY BASIC COLA TOTAL AUTHORIZED SIGNATORY (SignatureOver Printed Name) DESIGNATION
EMPLOYER SSS ID No./GOV'T AGENCY CODE BRANCH CODE
I HEREBY CERTIFY THAT THE ABOVE DATA AND INFORMATION ARE TRUE AND CORRECT.
PERMANENT
TEMPORARY
36
LEFT THUMBMARK
RIGHT THUMBMARK
FOR
HDMF ID NO. PFR NO. PFR DATE
HDMF
USE ONLY
PERIOD COVERED VERIFIED BY/DATE (Revised 5/2001)
AMOUNT P
Indicate if you are male or female Indicate if you are single, married, widowed or legally separated 6 Print your complete home address 7 Print your home telephone number 8 Print your birthdate in numeric format, e.g., April 27,1976, shall be written as 04-27-76 9 Indicate your place of birth 10 Indicate your HDMF identification number issued to you by Pag-IBIG Fund 11 Indicate your employees identification number issued to you by your employer 12 Indicate your Social Security System (SSS) Identification Number (for private employee) or GSIS Identification Number (for government employee) 13 Indicate your Tax Identification Number (TIN) issued by the Bureau of Internal Revenue (BIR) 14 For AFP Employee, indicate Serial/Account Number; for DECS Employee, indicate Division Code/Station Code/Employee Number 15 Indicate Pag-IBIG Housing Loan Identification Number issued by HDMF (for PagIBIG housing loan borrower) 16 Print complete name of your Company/Employer 17 Put an X mark to indicate Employer Category, if Private (an employed or selfemployed individual in the private sector); Government (an employed individual in the government sector) 18 Put an X mark to indicate if you have an existing or previous Pag-IBIG Housing Loan (for Pag-IBIG housing loan borrower) 19 Print the full address of your Company/Employer 20 Indicate the office telephone number of your Company/Employer 21 Print the name of your legal spouse 22 Print the name of your father 23 Print the name of your mother 24 List full name/s of your children, if any 25 Indicate the corresponding birthdate of your children 26 In case you do not have principal beneficiaries, list name/s of your other beneficiaries (relative within 6th civil degree of consanguinity) 27 Indicate the relationship of "other beneficiaries" with you (e.g. brother, sister, etc.) 28 List down the complete name of your employer/s (past and present starting 1980/ 1981) with whom you were registered as Pag-IBIG member 29 Indicate address/es of your previous employer/s 30 Indicate your membership category as follows: Employee any person in the service of an employer who receives compensation for such service; Self- Employed any person who has no employer and derives income from his own physical or mental effort; Other Working Groups Filipinos or aliens with permanent resident status in the Philippines recruited by a foreign employer or its agent for employment abroad; Non-resident Filipinos working abroad 31 Indicate the corresponding date start of employment (month and year) 32 Indicate the corresponding date end of employment (month and year) 33 Affix your signature and date of accomplishment of this form 34 Affix your three (3) specimen signatures 35 Affix your three (3) signature initials 36 Affix your left and right thumbmarks
4 5