Office of the President

NATIONAL HOUSING AUTHORITY

Northern & Central Luzon Office, Elliptical Road, Diliman, Quezon City
THE GENERAL MANAGER
Date:________________________
NHA, Diliman, Quezon City
SIR:
In accordance with NHA rules and regulations and provisions of RA 7279 which I and
my family agree to comply with faithfully, I am hereby applying to purchase/rent:
Residential Lot Only: ( ) Social ( ) Economic Lot; Described as
Lot
______
Block
______
Phase
______,
____________________________________ Project
House
and
Lot
Unit:
Lot
______
Block
______
Phase
______,
____________________________________ Project
Dwelling/Condominium Unit:
Bldg.
______ Unit
______,
____________________________________ Project
Mode of Payment: Cash: ____________ 6-Month Staggered Cash: ____________
Installment: ____________
A. APPLICANTS IDENTITY: (For female applicant maiden name only)
NAME:_______________________________________________________________________________________
_
(Rank)
(First Name)
(Middle Name)
(Last
Name)
Residential
Address:
_____________________________________________________________________________
Comm. Tax Cert.:
_______________ Issued On:_______________ Issued At:
____________________________
Place & Date of Birth:___________________________________ _________________
Citizenship:______________
Badge No.: _______________ Contact No.: ___________________
Email Address: __________________________
Office/Unit
Assignment:___________________________________________________________________________
Name of Spouse (For wife, give complete maiden name):
___________________________________________________________________________________________
(First Name)
(Middle Name)
(Last Name)
Place & Date of Birth of Spouse: ____________________________________ _________________
B. APPLICANTS FAMILY COMPOSITION:
NAME
RELATION TO APPLICANT
CIVIL STATUS
AGE
________________________________
_________________________
______________
_______
________________________________
_________________________
______________
_______
________________________________
_________________________
______________
_______
C. APPLICANTS TOTAL FAMILY INCOME PER MONTH: P_____________________
D. FAMILY REAL PROPERTY HOLDINGS: I and my wife,
( ) Do not own nor under contract to buy any lot/dwelling unit in the Philippines
( ) Own or under contract to buy the following lots/dwelling units as follows;
_________________________: Urban Residential
Total
Area
(sq.
m.)
____________________
_________________________: Commercial & Industrial
Total
Market
Value
P
__________________
E.
I
and
my
family
have
never
availed
assistance/accommodation, nor violated Section
14 of RA 7279.

of

any

government

housing

F. That I am not a professional squatter nor a member of squatting syndicate.

I hereby certify that I am making this application for the sole purpose of acquiring a
homelot for my family and not as DUMMY or AGENT of any other party.

Any false statement given by me hereinabove shall be sufficient cause for the
CANCELLATION of the award and contract that maybe executed by NHA in my favor as a
result of this application and the forfeiture of all payments that may have been made
therefore without prejudice to any administrative criminal or civil action, that maybe brought
by the NHA against me in accordance with existing laws.
________________________________
________________________________________
(Signature of Spouse)
Applicant)

(Signature

of

SUBSCRIBED AND SWORN to before me in ___________________________, Philippines,

this _____ day of _____________, 20___, AFFIANT, having exhibited to me his/her Community
Tax Certificate as stated above.
Doc. No.: __________________
Page No.: __________________
Book No.: __________________
Series of 20________

NOTARY PUBLIC