Republic of the Phitippines

SOCIAL SECURITY SYSTEM

CALAMITY LOAN ASSISTANCE APPLICATION
MLP-01282 {i; 7il16l

PLEASE READ THE INSTRUCTIONS AND REMINDTRS AT THI tsACK OF t*T TORU IT-IN IHE ATTACHED
]'ERMS AND CONDITiONS ACCOT\IPLISHIMG
THIS FORII, LLT :TTERS AND USE BLACK INK OI*LY.
PART TO BE FILLED OUT EY frIEMBER
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lf Mode ol Payment is Cash Card
PREFEREED BANK
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D C,libairk N A Philappines fl UnionBank c,f the Phitippines I
C. CERIIFICATION, UNDERTAKING AND PiOE4ISSORY NOTE
1. i certify that rny residence is located in the declared catamity area and was afiected ti (name cf calamity) yrhich
happened on icatej
2. I ce(rfy that my hcuselproperty was damaged by the sard calamity amounting to P
3 I cerli{y that the ia{ormation pravrded in this appl}cation
loim are true and correct.
4. ln case it is proven that I have given faise informatio* or rnisrBpresentation in this document or rn any other documents submitted rn conneciion
terlh my Cala|.llity Loan Assislance Applicaiion. the tolal ouistanding loan oalarce shail becorne due and demandaiti€ anC I prcm's€ to
immedrately pay in full the said amount
5 I ag.ee ulith ihe TERMS AND CONDiTIONS attaclred to this loan apptication.
6 I unconditionaliy promise to pay the amount staied rn ihe Orsclosure Statement under lhe Caiarnity Loan Assrslance Program that I have
c0nf.rme{i with

PRINTED NAfu1E OF MEMBER SIGNATURE DATE

PART |l - TO EE FILLEO OUr Ay EMPLOYER [rOnErnFIoYEE *reua l
A. EMPLOYER DATA
TAX iDENTIFICAI'ION NUMEER.

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TYPE OF E}{FLOYER

MPTOYER NA(,1E
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B, CERTIFICATION
iCeritfythaltheinformationprovidedlithis{o(naleirUeandccrre.iAisotagii
loan appiicatron

NTED NAME SIGNATURE posrirorl rrrt-r ----DATE--

PART III . TO B€ FILLED OUT BY SSS
NTIFICATIOI{ CARD'S OR DSCUi'ENTIS PRESST$TEN CEIVTD ANO ENCOI]ED BY

I Primery to cara

I Turo vati* tO cards, both wl signature & augast one w, !*Eto SIGNATURE OVER PRiNT[D I.IAME POSITION TITLE DATE AND TIME BRANCH
I O*,er tE cardrs or occuments /iEWED BY

arcNAirRE otER PRTNTED ,tE- posrTroN L OAI€ AND Tll\,1f

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Re0ublic ol the Phitippifles
SOCIAL SECURITY SYSTEM
CALA.MITY LOAN ASSISTANCE APPLICATION
ACKNOWLEDGEMENT STUB
SS NO.ICCMMON REFER€NCE N0 rrr +: NAME r:S- !,;\iF ;iaS- 11;rr.E, il'a):r.E:i]i[1:
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EIVED BY

SIGNAIURE CVER PRINTED NAME poslrioN l rTL5 DATE & TIME SRANCH