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FOR HDMF USE ONLY

Pag-BG MD No.
REGISTRATION TRACKING NO.: 911146020078
INSTRUCTIONS
1. The Member's Data Form (MDF) shall be accomplished in two(2) copies. 6.
On the 'BENEFCARES' portion, the provision on the intestate
Succession, as Provided in the New Family Code shall be observed.
a. SNGLE - Mother, Father, Brother and/or Sister.b. MARRED - Spouse, Son,
Daughter, Mother and Father
2. Type or print all entries in BLOCK or CAPTAL LETTERS.
3. The 'NAME EXTENSON' shal refer to JR., , and the like.
4. ndicate the full name of your FATHER and MOTHER as they appear in
you birth certificate.
7. Submit MDF in two (2) copies and present at least one (1) valid primary D.
5. Accomplish only the 'PERMANENT HOME ADDRESS' if it is different
with the 'PRESENT HOME ADDRESS'.
8. For any subsequent change of information, please secure and accomplish
two (2) copies of the Member's Change of nformation Form (MCF)
[FPF110] and submit to the concerned HDFM Branch.
MEMBERSHIP CATEGORY
EMPLOYED PRVATE SELF-EMPLOYED NOT YET EMPLOYED
EMPLOYED GOVERNMENT EMPLOYED PRVATE HOUSEHOLD
OVERSEAS FLPNO WORKER (OFW) NDVDUAL PAYOR
LAST NAME FIRST NAME
NAME
EXTENSION
(e.g. Jr., )
MIDDLE NAME
NO MIDDLE NAME
(check if applicable
only)
MEMBER LAFORTEZA REYNALDO JUANITO LUDO

FATHER LAFORTEZA RICARDO R

MOTHER (Maiden Name)
LAFORTEZA BEATRIZ M

SPOUSE (f Married)
FLORENDO DONNABELLE BUQUING

MEMBERS'S NAME AS APPEARING
IN THE BIRTH CERTIFICATE
LAFORTEZA REYNALDO JUANITO LUDO

DATE OF BIRTH
DECEMBER 2, 1975
CIVIL STATUS
MARRIED
TAXPAYERS IDENTIFICATION NO.
923 311 703
SSS NUMBER
0219500919
GSIS NUMBER
EMPLOYEE NUMBER
......................................
....e.e............e.e.e..e.e...e.e.e..e.e...
-
PLACE OF BIRTH
DAGUPAN CITY, PANGASINAN,
PHILIPPINES
CITIZENSHIP
FILIPINO
GENDER
MALE
PROMINENT DISTINGUISHING FACIAL FEATURES
COMMON REFERENCE NUMBER (CRN)/UNIFIED MULTI-PURPOSE ID NO.
PRESENT HOME ADDRESS CONTACT DETAILS
Unit/Floor/Room No. Building
(ndicate country code if abroad)
COUNTRY + AREA CODE TELEPHONE NUMBER
Home
Cell Phone
Business (Direct Line)
Business (Trunk Line)
Email Address
rjlaforteza@yahoo.com
Lot No. Block No. Phase No. House No. Street
OLAYA
Subdivision Barangay
Municipality/City Province/State(if abroad)
, RIYADH RIYADH
Counry(if abroad) ZP Code
SAUDI ARABIA 11461

PERMANENT HOME ADDRESS
Unit/Floor/Room No. Building Lot No. Block No. Phase No.
5 12
House No. Street Subdivision Barangay
Page 1 oI 2 MEMBER'S DATA FORM (MDF) PRINT (NO. 911146020078)
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LA TRINIDAD VILLAGE TALIPAPA
Municipality/City Province Zip Code
QUEZON CITY 1116
PREFERRED MALNG ADDRESS
Present Home Address Permanent Home Address Employer/Business Address
EMPLOYMENT/BUSINESS DETAILS
EMPLOYER/BUSINESS NAME
SAMAMA COMPANY FOR OPERATIONS AND MANAGEMENT
EMPLOYMENT STATUS
Permanent/Regular Contractual
Casual Project-based
Part-time/Temporary
EMPLOYER/BUSINESS ADDRESS
Unit/Floor/Room No. Building DATE STARTED
MARCH 2011
Lot No. Block No. Phase No. House No. Street
OLAYA
MONTHLY INCOME
Basic 0.00
Allowances/Others 0.00
Gross 0.00
Subdivision Barangay
Municipality/City Province/State(if abroad)
RIYADH KINGDOM OF SAUDI ARABIA
OCCUPATION
OFFICE AND ADMINISTRATIVE
SUPPORT WORKERS, ALL OTHER
Counry(if abroad) ZP Code
SAUDI ARABIA 11461
TYPE OF WORK (For OFWs only)
Land-based Sea-based
MANNING AGENCY (To be accomplished by the seafarers only) ASSIGNED COUNTRY (Land-based only)
SAUD ARABA
EMPLOYMENT HISTORY FROM DATE OF HDMF MEMBERSHIP (Please indicate by your previous employer/s)
EMPLOYER/BUSNESS NAME
NATIONAL GRID CORPORATION OF THE PHILIPPINES
FROM
JULY 2009
TO
MARCH 2011
EMPLOYER/BUSNESS ADDRESS
LABRADOR, PANGASINAN, PHILIPPINES
EMPLOYER/BUSNESS NAME
NATIONAL TRANSMISSION CORPORATION
FROM
APRIL 2003
TO
JUNE 2009
EMPLOYER/BUSNESS ADDRESS
EMPLOYER/BUSNESS NAME
MIRANT SUAL PHILIPPINES
FROM
SEPTEMBER 2002
TO
NOVEMBER
2002
EMPLOYER/BUSNESS ADDRESS
BENEFICIARIES (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)
LAST NAME FIRST NAME
NAME
EXTENSION
MIDDLE NAME
NO MIDDLE NAME
(Check only if applicable)
RELATIONSHIP DATE OF BIRTH
LAFORTEZA DONNABELLE FLORENDO SPOUSE March 4, 1979
LAFORTEZA DIONNE REYVEN FLORENDO SON August 17, 2010
LAFORTEZA JOHN REYNIER FLORENDO SON April 27, 2007
LAFORTEZA RICARDO RILLORAZA FATHER August 29, 1937

I HEREBY CERTIFY THAT THE INFORMATION GIVEN AND ALL STATEMENTS
MADE HEREIN ARE TRUE AND CORRECT.
SIGNATURE OF MEMBER DATE
SPECIMEN SIGNATURES INITIALS
Page 2 oI 2 MEMBER'S DATA FORM (MDF) PRINT (NO. 911146020078)
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