Annex B-1

LAND BANK OF THE PHILIPPINES

LIVELIHOOD LOAN APPLICATION/AGREEMENT FORM FOR DEPED

Revised 5/2014

(Please read Terms and Conditions at the back before filling up this form)

TO BE FILLED UP BY APPLICANT/BORROWER
Type of Loan:

New

New with Take-out

Renewal

Renewal with Take-out

Regional Code

Station Code

PN Number

Residence Address

Zip Code

Tel. No.

Provincial Address

Zip Code

Tel. No.

APPLICANT (First Name, M.I., Surname)

Birthdate

Age

Type
Rank & File

Gender
Male

Female

Civil Status
Single

Division Code

Department/Office/School
Married

Widow/er

Position

Employee No.

Years In Service

Office/School Address:

TIN

Basic Pay

Net Pay

LANDBANK Payroll Account Number

Officer

GSIS No.

LOAN TAKE-OUT AGREEMENT

I hereby authorize LANDBANK to take-out my existing loan with the following Private Loan Institution/s (PLI/PLIs):
Name of PLI/PLIs

Loan Outstanding
Balance

Complete Address

Contact Number

1)
2)
3)
4)
5)
6)
7)

I further authorize LANDBANK to:

1) issue a check payable to the PLI/PLIs representing the outstanding balance of the loan;
2) remit the check/payment directly to the PLI/PLIs;
3) receive the official receipt and Certificate of Full Payment from the PLI/PLIs; and
4) Upon crediting of loan proceeds, withhold the balance of my payroll account and on the following day of crediting of loan proceeds, withhold up to the
amount of the net loan proceeds pending receipt of the Certificate of Full Payment and Official Receipt from the PLI/s.
I hereby swear that I will be responsible to pay in full whatever difference in the amount of the check/payment and the latest balance of my existing loan with
the above PLI/PLIs, If any.

Signature Over Printed Name of Borrower

APPLICATION/AGREEMENT/PROMISSORY NOTES
I hereby apply for a Livelihood Loan in the amount of PESOS ________________________________________________________ (P _______________) .
I hereby swear that: (1) I am up-to-date in the payment of my existing loan/s; (2) I have no pending application for retirement or are not due for
retirement within the next ______ years from execution hereof; (3) I have no pending loan application with other agencies/institutions; (4) I am a regular/permanent
employee of the __________________________________________ ; (5) I am not a respondent/party of any pending administrative or criminal cases; and
(6) the statements declared above are true and correct to the best of my knowledge and that the application is made for the purpose and consideration expressed
above. I agree that should there be any misrepresentation discovered, the Land Bank of the Philippines may cause the outright disapproval of the loan application
and if the loan has already been granted, LANDBANK may immediately declare the loan due and demandable.
I promise to pay to LANDBANK the amount applied for in accordance with the terms and conditions printed at the back thereof, which I acknowledge to have
read and clearly understood.
I hereby authorize:
the Accounting Department or Collecting Officer of DepEd to deduct the monthly installment on this loan from my salary or from any form of benefits
due me for payment/application to the monthly amortization on this Loan, until the loan and all interest and fees related thereon are fully paid.

LANDBANK to debit my ATM Payroll account No. ___________________ for payment/application to the monthly amortization on this loan, until the
loan and all interest and fees related thereon are fully paid.

LANDBANK to inform the DepEd on the crediting of the loan proceeds and the status of my deposit and loan accounts.
Signature Over Printed Name of Borrower

(To be filled up by Employer)

EMPLOYER CERTIFICATION
Office :
This Office certifies that:

Date :

(1) the above information and signatures of applicant/borrower are authentic;

(2) the above applicant:
is permanent/appointed employee of this Office and has been in the service for at least one year and is not on leave of absence without pay;
has no pending administrative and/or criminal charges against him;
has no pending application for retirement or is not due for retirement within the term of the loan
is up-to-date to the payment of his existing loans, if any ;
is presently receiving a net take home pay of not less than P_____________ after statutory deductions and net of all loan of all amortizations
including the livelihood loan applied for.
This Office certifies that the net take home pay of the applicant/borrower as of _______________ amounted to PESOS __________________________
_________________________________ (P_____________).
This Office agrees to collect the monthly installment/amortizations due on the loan of the borrower through automatic salary deduction and remit
immediately to LANDBANK not later than five (5) banking days after payroll date.
Name in Print

Designation

Signature of Authorized Signatory

TO BE FILLED UP BY LANDBANK
EXISTING LOAN: Borrower
Date Granted
:
Amount Granted
:
:
Outstanding Balance
Arrearages
:

Processed by:

EXISTING LOAN: Agency/Entity

Total Outstanding Balance
P
Current
P
Technical Past Due/Rate
P
Actual Past due/Rate
P
Combined Past Due/Rate
P
-

Reviewed by:

as of

DOCUMENT CHECKLIST
( ) Photocopy of Company/Office ID
( ) Certified True Copy of Latest Payslip

%
%
%

( ) Certificate of Employment
( ) SOA/OS Balance from PLI certified by employee
( ) Others _______________________

Approved by:

Branch Head