Republic of the Philippines

DEPARTMENT OF EDUCATION
Regional Office No. 02 (Cagayan Valley)
SCHOOLS DIVISION OFFICE OF ISABELA

DEPED PROVIDENT FUND LOAN FORM

Application No.: __________
( ) New ( ) Renewal
BORROWER: CO-MAKER:

________________ __________________________ ______ ____________________ __________________________ ____

(Last Name) (First Name) M.I. (Last Name) (First Name) M.I.

Present Address: ____________________________________ ____________________________________________________

Home Address: ____________________________________ ____________________________________________________
Date of Birth: ____________________________________ ____________________________________________________
School: ____________________________________ ____________________________________________________
Mo. Salary (Gross) : _________________________________ ____________________________________________________
Div. No. _____ Sta. No. ______ Emp. No. ______________ Div. No. ______ Sta. No. _______ Emp. No. _______________
TIN: ______________________________________________ TIN: _______________________________________________

______________________ _____________________ ________________________ ________________________

Specimen’s Signature Specimen’s Signature Specimen’s Signature Specimen’s Signature
APPLICATION / AGREEMENT APPLICATION / AGREEMENT
I hereby apply for an emergency loan in the amount and at the amortization Should the principal borrower be separated from the service and there are no
schedule stated below. In consideration of the grant thereof, I promise to pay all retirement nor separation benefits due him/her, I hereby agree to assume all his
installments due and bind myself to the terms and conditions of the monthly amortization outstanding obligation for the grant of this loan upon proper notification by the Provident
from my salary when due. Should I be separated from the service, I also hereby Fund Secretariat. Accordingly, I hereby authorize the monthly deduction from my salary
authorized the deductions in full of any unpaid balance from my retirement or separation the amortizations for the outstanding obligation of the principal borrower until his/her
benefits. loan has been fully paid.
Amount of Loan Amortization Schedule

(12 mos.) (24 mos.) (36 mos.) (60 mos.)

________________________________
( ) 50,000.00 4,416.44 2,333.33 1,638.88 1,083.33 Signature of Co-Maker
( ) 45,000.00 3,975.00 2,100.00 1,475.00 975.00
( ) 40,000.00 3,533.33 1,866.66 1,311.11 866.66
( ) 35,000.00 3,091.66 1,633.33 1,147.22 758.33 _____________________
( ) 30,000.00 2,650.00 1,400.00 983.33 650.00 Date
( ) 25,000.00 2,208.33 1,166.66 819.44 541.66
( ) 20,000.00 1,766.66 933.33 655.55 433.33
( ) 15,000.00 1,325.00 700.00 491.66

______________________ _______________
Signature of Borrower Date

CERTIFICATION OF EMERGENCY LOAN

I hereby certify that the proceeds of the above loan shall be as follows:
_______________________________________________
________________________
(Signature of Borrower)

AUTHORIZATION FOR SALARY DEDUCTION

The Chief
Cash Division, Payroll Services Division
Department of Education
Carig, Tuguegarao City
Attention: The Cashier/Disbursing Officer
Sir/Madam:
I hereby authorized the deduction from my salary the amount of _____________________ PESOS (P_________) every month
for _____ months starting in ____________or until my total loan amount of_________________________ has been paid. Amount
deducted shall be credited to the account of the DepED Provident Fund as amortization of said loan.

_________________________________________
(Signature over Printed Name)

Div. No. ____ Sta. No. _____ Employee No. _____________ Division: _________________________________
Designation/Position: _______________________________ Province: ________________________________
Employment Status _________________________________
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Regional Office No. 02 (Cagayan Valley)
SCHOOLS DIVISION OFFICE OF ISABELA

AUTHORIZATION FOR SALARY DEDUCTION

Office: _______________________________________________________ Date:_____________________________

This Office certifies that: (1) the above applicant is a permanent employee of this Office is not on leave of
absence without pay; (2) there is no administrative and/or criminal charges against him/her; (3) the net pay of the
borrower indicated above is sufficient to cover monthly installments of this loan: (5) the information by said applicant
is true and correct.

___________________________________________
Signature of Head of Office or
Authorized Representative/
Endorsing Official

____________________________________
SUSAN MARIE P. BARTOLOME, PhD
Administrative Officer V

ACTION TAKEN:

( ) APPROVED

( ) DISAPPROVED

( ) OTHERS

___________________________________
MADELYN L. MACALLING,PhD. CESO VI
Schools Division Superintendent

REQUIREMENTS FOR PROVIDENT FUND LOAN APPLICATION

(Loan Deficiency Checklist)

( ) Three (3) copies Voucher Form.

( ) Three (3) copies of Provident Fund Loan Form Application duly signed by the Head of Office or Authorized
Representative/Endorsing Official.

( ) One (1) copy of original and certified true Xerox copy of the latest payslip/payroll of the Applicant and the Co-
Maker.

( ) The gross monthly salary of the Co-Maker should be equal or higher than the gross salary of the Applicant.

( ) The net take home pay of the Applicant should be at least Php 5,000.00 after deducting the loan.

( ) For renewal, the Applicant should be fully paid or at least paid half from his/her previous loan at the date of
the application.

FM- SDS -GSU-005 REV. 00