HQP-HLF-182

APPLICATION FOR CONVERSION

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

HL ACCOUNT NUMBER

Pag-IBIG MID No./RTN

DESIRED RE-PRICING PERIOD (in years)

PROPERTY LOCATION
Unit/Room No., Floor
Subdivision

LAST NAME

10

WITH PDC

15

Building Name

Municipality/City

FIRST NAME

NAME EXTENSION

PERMANENT HOME ADDRESS

Building Name

Subdivision

WITH ADDITIONAL LOAN?

Yes

Barangay

Yes

IF WITH ADDITIONAL LOAN, RE-PRICING SHALL BE

APPLIED ON?

Original Loan only

Additional Loan only

No

MODE OF PAYMENT
Salary Deduction
Over-the-Counter
Cash/Check
Post-Dated Checks

Street Name

Province and State Country (if abroad)

BORROWERS DATA
CITIZENSHIP

MIDDLE NAME

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

Municipality/City

No

AVAILED OF RESTRUCTURING?

WITHOUT PDC

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

Barangay

Unit/Room No., Floor

LOAN PARTICULARS

MARITAL STATUS

Zip Code

Single/
Unmarried
Married
Widow/er
CONTACT DETAILS
abroad)

Building Name

Subdivision
abroad)

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

Barangay

Municipality/City

HOME OWNERSHIP
Owned
Company
Living w/ relatives/parents
Mortgaged
Rented at P__________/mo.
EMPLOYER/BUSINESS NAME (If self-employed)
EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor

Building Name

Subdivision

Barangay

Municipality/City

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

FIRST NAME

EE SSS/GSIS ID No.

YEARS OF STAY IN PRESENT

HOME 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

PARTICULARS

BASIC MONTHLY COMPENSATION

COST OF LIVING ALLOWANCE

OTHER SOURCE/S

Legally
Separated
Annulled
(Indicate country code if

Street Name.

Province and State Country (if abroad)

Cell Phone
Email Address
CONTACT DETAILS (Indicate country code if
abroad)

TIN

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

NAME EXTENSION

Zip Code

COUNTRY + AREA CODE TELEPHONE NO.

OCCUPATION
Employed
Self-Employed

Zip Code

Business (Direct Line)

Business (Trunk Line)

Employer/Business Email Address

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

SPOUSES PERSONAL DATA

MIDDLE NAME

CITIZENSHIP

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

DATE OF BIRTH (mm/dd/yy)

EMPLOYER/BUSINESS NAME (If self-employed)

EMPLOYER/BUSINESS ADDRESS

Home

Street Name

Province and State Country (if

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

INDUSTRY

LAST NAME

SEX

COUNTRY + AREA CODE TELEPHONE NO.

PRESENT HOME ADDRESS

Unit/Room No., Floor

Collecting Agent
Bank
Developer
Remittance
Center

DATE OF BIRTH (mm/dd/yy)

Street Name

Province and State Country (if abroad)

Both loans

TIN
YEARS IN EMPLOYMENT/
BUSINESS

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

Municipality/City

Street Name

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

OCCUPATION
Employed
Self-Employed

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

GROSS MONTHLY INCOME

PRINCIPAL BORROWER

POSITION & DEPARTMENT

Zip Code

BUSINESS TEL. NO.

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

SPOUSE

BANK ACCOUNTS
BANK

(Indicate your 3 most active)

TYPE OF
ACCOUNT

BRANCH/ADDRESS

ACCOUNT NO.

DATE OPENED

AVE. BALANCE

CREDIT CARDS OWNED

(Indicate your 3 most active)
CARD TYPE
(e.g. Visa/Mastercard)

ISSUER NAME

REAL ESTATE OWNED

TYPE OF
PROPERTY

LOCATION

ACQUISITION
COST

TCT NO.

MARKET VALUE

OUTSTANDING CREDITS/LOAN AVAILMENTS

Creditor & Address

Security

Creditor & Address

Security

Creditor & Address

(August 2012)

CARD EXPIRY
(mm/yyyy)

Security

CREDIT LIMIT

MORTGAGE
BALANCE

RENTAL INCOME

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

ACCOUNT TAKEN OUT UNDER CIRCULAR 247?

YES

TAKE-OUT DATE ________________

UPDATED

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.