For Express Home Rehabilitation/Reconstruction Loan

HQP-HLF-453
SWORN DECLARATION OF BEING AFFECTED BY CALAMITY
I, _________(name of member)_____________, of legal age, ____(civil status)__,
Filipino and with permanent address at __________________________________,
hereby certify that:
1. I am a Pag-IBIG Fund member in good standing;
2. I am applying for a home rehabilitation/reconstruction loan with Pag-IBIG Fund;
3. I am a victim of _______(name or nature of calamity)____ , and my
house/residence at ________________________________________________
was among those destroyed or damaged on ___________________.
4. Due to the above-stated calamity, I have suffered the following damages/effects
in my property:
(describe damages/effects of calamity)

5. I am executing this Sworn Declaration to attest to the truthfulness of the

foregoing facts.
6. I am aware that any fraud, misrepresentation, or misstatement of any relevant
fact which attended or accompanied my aforementioned application shall be a
ground for Pag-IBIG Fund to take action against me.
___________________________________
Signature over Printed Name of Member
No.
Date of Issue
Expiry Date

REPUBLIC OF THE PHILIPPINES )

PROVINCE/CITY OF _______________) S.S.

BEFORE ME, a Notary Public for and in the _______________________,

Province/City of _____________________, this ______ day of _____________,
_______, personally appeared the above-named person/s, who has satisfactorily proven
to me his/her identity through his/her identifying documents written below his/her name
and signature, that he/she is the same person who executed the foregoing instrument
which he/she acknowledged before me as his/her free and voluntary act and deed.
WITNESS MY HAND AND
_____________, ______, in the
_____________________.

NOTARIAL SEAL, this ______ day

_______________________, Province

of
of

NOTARY PUBLIC
Doc. No. _______;
Page No. _______;
Book No. _______;
Series of _______.
(Rev. 00, 12/2014)