MEMBER'S DATA FORM (MDF) PRINT (NO.

911146020078)

MEMBER'S DATA FORM (MDF)

FOR HDMF USE ONLY Pag -IBIG MID No.

REGISTRATION TRACKING NO.:

INSTRUCTIONS

911146020078
6. On the 'BENEFICIARIES' portion, the provision on the intestate
Succession, as Provided in the New Family Code shall be observed. a. SINGLE - Mother, Father, Brother and/or Sister.b. MARRIED - Spouse, Son, Daughter, Mother and Father

1. The Member's Data Form (MDF) shall be accomplished in two(2) copies. 2. Type or print all entries in BLOCK or CAPITAL LETTERS. 3. The 'NAME EXTENSION' shal refer to JR., II, II and the like. 4. Indicate 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 ID. 8. For any subsequent change of information, please secure and accomplish
two (2) copies of the Member's Change of Information Form (MCIF) [FPF110] and submit to the concerned HDFM Branch.

5. Accomplish only the 'PERMANENT HOME ADDRESS' if it is different

with the 'PRESENT HOME ADDRESS'.

MEMBERSHIP CATEGORY EMPLOYED PRIVATE EMPLOYED GOVERNMENT OVERSEAS FILIPINO WORKER (OFW) SELF-EMPLOYED EMPLOYED PRIVATE HOUSEHOLD INDIVIDUAL PAYOR NAME LAST NAME FIRST NAME EXTENSION
(e.g. Jr., II)

NOT YET EMPLOYED

NO MIDDLE MIDDLE NAME NAME (check if

applicable only)

MEMBER FATHER MOTHER (Maiden Name) SPOUSE (If Married)

MEMBERS'S NAME AS APPEARING IN THE BIRTH CERTIFICATE

LAFORTEZA LAFORTEZA LAFORTEZA FLORENDO LAFORTEZA

REYNALDO JUANITO RICARDO BEATRIZ DONNABELLE REYNALDO JUANITO CIVIL STATUS

LUDO R M BUQUING LUDO TAXPAYERS IDENTIFICATION NO.

DATE OF BIRTH

DECEMBER 2, 1975
PLACE OF BIRTH CITIZENSHIP

MARRIED

923 311 703

SSS NUMBER

DAGUPAN CITY, PANGASINAN, PHILIPPINES

GENDER

FILIPINO

0219500919
GSIS NUMBER

PROMINENT DISTINGUISHING FACIAL FEATURES

MALE
COMMON REFERENCE NUMBER (CRN)/UNIFIED MULTI-PURPOSE ID NO.

EMPLOYEE NUMBER

For AFP/PNP Employee, Serial/Badge No.

For DECS Employee, Division Code-Station Code

PRESENT HOME ADDRESS

Unit/Floor/Room No. Building

CONTACT DETAILS
(Indicate country code if abroad) COUNTRY + AREA CODE TELEPHONE NUMBER

Lot No.

Block No.

Phase No.

House No.

Street

Home

OLAYA
Cell Phone

http://www.pagibigfund.gov.ph/PubReg/MemberRegistration/MDFNew.aspx?MDFNO=6FE056CABDB9AB968EF663D756[5/26/2011 4:26:37 PM]

MEMBER'S DATA FORM (MDF) PRINT (NO. 911146020078)

Subdivision Barangay

Business (Direct Line) Municipality/City Province/State(if abroad)

, RIYADH
Counry(if abroad)

RIYADH
Business (Trunk Line) ZIP Code

SAUDI ARABIA

11461

Email Address

rjlaforteza@yahoo.com

PERMANENT HOME ADDRESS

Unit/Floor/Room No. Building Lot No. Block No. Phase No.

5
House No. Street Subdivision

12
Barangay

LA TRINIDAD VILLAGE
Municipality/City Province

TALIPAPA
Zip Code

QUEZON CITY
PREFERRED MAILING ADDRESS

1116
Present Home Address Permanent Home Address Employer/Business Address

EMPLOYMENT/BUSINESS DETAILS EMPLOYER/BUSINESS NAME EMPLOYMENT STATUS Permanent/Regular EMPLOYER/BUSINESS ADDRESS Casual Contractual Projectbased

SAMAMA COMPANY FOR OPERATIONS AND MANAGEMENT

Part-time/Temporary
Unit/Floor/Room No. Building

DATE STARTED

MARCH 2011
Lot No. Block No. Phase No. House No. Street

MONTHLY INCOME
Basic Allowances/Others Gross

OLAYA
Subdivision Barangay

0.00 0.00 0.00

Municipality/City

Province/State(if abroad)

OCCUPATION OFFICE AND ADMINISTRATIVE SUPPORT WORKERS, ALL OTHER

RIYADH

KINGDOM OF SAUDI ARABIA

Counry(if abroad)

ZIP Code

TYPE OF WORK (For OFWs only) Land-based Sea-based

SAUDI ARABIA

11461

MANNING AGENCY (To be accomplished by the seafarers only)

ASSIGNED COUNTRY (Land -based only)

SAUDI ARABIA

EMPLOYMENT HISTORY FROM DATE OF HDMF MEMBERSHIP (Please indicate by your previous employer/s) EMPLOYER/BUSINESS NAME FROM TO

NATIONAL GRID CORPORATION OF THE PHILIPPINES

EMPLOYER/BUSINESS ADDRESS

JULY 2009

MARCH 2011

LABRADOR, PANGASINAN, PHILIPPINES

EMPLOYER/BUSINESS NAME FROM TO

http://www.pagibigfund.gov.ph/PubReg/MemberRegistration/MDFNew.aspx?MDFNO=6FE056CABDB9AB968EF663D756[5/26/2011 4:26:37 PM]

MEMBER'S DATA FORM (MDF) PRINT (NO. 911146020078) NATIONAL TRANSMISSION CORPORATION
EMPLOYER/BUSINESS ADDRESS EMPLOYER/BUSINESS NAME FROM TO

APRIL 2003

JUNE 2009

MIRANT SUAL PHILIPPINES

SEPTEMBER 2002

NOVEMBER 2002

EMPLOYER/BUSINESS ADDRESS BENEFICIARIES

LAST NAME

(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)

FIRST NAME

NAME EXTENSION

MIDDLE NAME

NO MIDDLE NAME
(Check only if applicable)

RELATIONSHIP

DATE OF BIRTH

LAFORTEZA LAFORTEZA LAFORTEZA LAFORTEZA

DONNABELLE DIONNE REYVEN JOHN REYNIER RICARDO

FLORENDO FLORENDO FLORENDO RILLORAZA

SPOUSE SON SON FATHER

March 4, 1979 August 17, 2010 April 27, 2007 August 29, 1937

SPECIMEN SIGNATURES I HEREBY CERTIFY THAT THE INFORMATION GIVEN AND ALL STATEMENTS MADE HEREIN ARE TRUE AND CORRECT.

INITIALS

SIGNATURE OF MEMBER

DATE

http://www.pagibigfund.gov.ph/PubReg/MemberRegistration/MDFNew.aspx?MDFNO=6FE056CABDB9AB968EF663D756[5/26/2011 4:26:37 PM]