Provident Form

Republic of the Philippines
Department of Education
Negros Island Region
SCHOOLS DIVISION OF DUMAGUETE CITY
Dumaguete City
PROVIDENT FUND
Loan Application No. _________
BORROWER: CO-MAKER:
________________________________________ _______________________________________
(Last Name) (First Name) (M.I.) (Last Name) (First Name) (M.I.)
Present Address : _________________________ Present Address : _________________________
Home Address : _________________________ Home Address : _________________________
Contact No. : _________________________ Contact No. : _________________________
Date of Birth : _________________________ Date of Birth : _________________________
Position : _________________________ Position : _________________________
Monthly Salary : ____________ Status: ______ Monthly Salary : ___________ Status: ______
Office : _________________________ Office : _________________________
Employee No. : _________________________ Employee No. : _________________________
TIN : _________________________ TIN : _________________________
Specimen Signature: Specimen Signature:
1. _____________________________________ 1. ____________________________________
2. _____________________________________ 2. ____________________________________
AMORTIZATION AGREEMENT
I hereby apply for a Provident Loan in the amount and at Should the principal borrower be separated from the
the amortization schedule stated below. In consideration of the service and there are no retirement nor separation benefits
grant thereof, I promise to pay all installments due and bind to due him, I hereby agree to assume all his corresponding
the terms and conditions of the loan. Accordingly, I hereby obligation for the grant of this loan upon proper notification
authorize the deduction of the monthly amortization from my by the Provident Secretariat. Accordingly, I hereby
salary when due. Should I be separated from the service, I also authorized the monthly deduction from my salary the
hereby authorize the deduction in full of any unpaid balance amortization for the outstanding obligation of the principal
from my retirement or separation benefits. borrower until his loan has been fully paid.
AMOUNT OF LOAN AMORTIZATION SCHEDULE
______________ _____________ ________mos.

Principal Amortization Repayment Period
____________________________________________
___________________________ _______________
(Co-Maker’s Signature o Printed Name)
(Signature of Borrower) (Date)
CERTIFICATION FOR LOAN
I hereby certify that the proceeds of the above loan shall be used as follows:
(a) Emergency Loan
(b) Educational Loan
(c) Loan due to sudden loss of income
(d) Others, (Pls. Specify) __________________________________________________
______________________________________
(Signature of Borrower)
_____________________________________________________________________________________
AUTHORIZATION FOR SALARY DEDUCTION
____________________________
____________________________
____________________________
Sir/Madam:
I hereby authorize the deduction from my salary the amount of _____________________________________________

(P ____________________) every month for ____________ (______) months starting in ____________ or until my total loan
amount of PESOS: _____________________________ (P________________) shall have been fully paid. Amount deducted shall
be credited to the account of the DepEd Provident Fund as Amortization on said loan.
________________________________________
(Signature over Printed Name)
Employee Number : ____________________________________ Division : _____________________

Designation/Position: ____________________________________ Service/Center Bureau: _____________________
Station Code : ____________________________________
CERTIFICATION OF EMPLOYMENT AND CREDIBILITY
Office: _____________________________________ Date: __________________________
This Office certifies that (1) the applicant is a permanent employee of this Office and is not on
leave of absence without pay; (2) there is no pending administrative and/or criminal charge against
him/her; (3) the net pay of the borrower indicated is sufficient to cover monthly installments of this loan;
(4) the applicant is not due for retirement for the next ________ ( ) years; and (5) the information
reported by said applicant is true and correct.
________________________________________________________
Signature of Head of Office/School or authorized Representative/Indorsing Official
___________________________________________
Name in Print
___________________________________
Designation
ACTION TAKEN BY DIVISION SECRETARIAT
Recommending: Approval: ______________ Disapproval: _______________
MERLYN B. TAMPARONG GAUVIN T. ABSIN

Education Program Supervisor Accountant III
Member Member
MONINA U. LACSON
Administrative Officer V
Chairman
Approved/Disapproved by:
EVANGEL M. LUMINARIAS, Ph. D., CESO V

Schools Division Superintendent/Head of Office

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Republic of the Philippines

AMOUNT OF LOAN AMORTIZATION SCHEDULE

________ _ __mos.

CERTIFICATION FOR LOAN

I hereby authorize the deduction from my salary the amount of _____________________________________________

Employee Number : ________________ Division : _

Office: ___________ Date:

ACTION TAKEN BY DIVISION SECRETARIAT

Recommending: Approval: Disapproval: _

MERLYN B. TAMPARONG GAUVIN T. ABSIN

EVANGEL M. LUMINARIAS, Ph. D., CESO V

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