Y ,.

LOAN DOCUMENTS SUBMISS ON FORM

A. Ghecklist to be fil ed up bv the Applicant

NAME OF BORROWER: /
(RANK) (F RST NAME) (M DDLE NAME) (LAST NAME)

r' LOAN TYPE: E POU CY LOAN ESALARY LOAN PLUS E EMERGENCY LOAN
E UUII .PURPoSE LoAN f]cauu w LoAN
/ AMOUNT OF LOAN: r' TERM:

E NEW LOAN f]RE-LOAN

PLEASE CHECK DOGUMENTS SUBM TTED:

tr
Application Form and Promissory Note
tr
Authority to Deduct duly notarized
tr
Payslip of borrower (latest 2 months)
tr
Corporate lD (not expired/back to back) with 3 specimen signatures
tr
Certificate of Non-pending Case (not applicable for Policy Loan)
tr Certificate of Active Duty Status from Station/U nil (not appticable for Poticy Loan)
tr Deed of Undertaking duly notarized (for PNP personnel only)
tr Other documents:

F LED BY= /
ve
Name and Slgneturc of ApplicanuReofef,enta Date

FOR PS BF USE ONLY **'*!****

B. d bv PS BFI Dersonne receivinq the loan app ication :

Did the applicant personallv submit the loan application and other E YES E lrto
documents to you?

If the answer is YES, do you attest that: Specimen srgnatures were fIYES E No
pensonally, affixed by the applicant in your presence and vertfid that
the said signatures are similar to the signaturc appearing in the
identification ca rdls presented?

lf the answer is NO, please answer the following:

a. Did you require authorized representative to present his original flves Eruo
copy of lD? Please obtain copies of the authorization and lDls
presented and attached the same to this document.

b. Did you verify by way of tetephone calt to the applicant the veracity EYES E trto
of the loan application? Please indicate telephone number

c. Did the member/applicant acknowledge his loan application? flvrs E ruo

2. Do you certify that:

a. all required documents are submitted and are in original copies? E Yes fl No
b. the scanned and e-mailed documents are the honest and truthfu! E Yes ENO
reproduction of the original documents in your possession?

3. Do you certify that there are no conditions like medical illness, pending case, E YES E NO
or any other condition known to you at the time of loan application,
that will cause non-payment of loan amortization by the applicant?

By pmviding my signature below, I hereby confirm that all information disclosed above is conect and complete

Name and Signature of PSMBFI personnel Date

 PSMBFI
PUBLIG SAFETY MUTUAL BENEFIT FUND, ING.
318 - 320 comer 1"t and 2d Streets, Brgy. West Crame, Bonnie Serrano Ave., San Juan City
Trunk Lines 872G8070, 8727-3959,E-Mail psmbfi @info.com.oh Extension Offi ce/Branch

LOAN APPL CAT ON FORM

LOAN PARTICUTARS
Loan Type: LJ pt U SL Ptus lJ Emergency lJ Uultifurpose LIcL U Others
DATE:

! New Loan PAYUENTTERTS

! Renewal tl 12 months ! 18 months ! 24 months E 36 months E 48 months ! 60 Months
ATOUNT (ln Words): ATOUNT (ln figures):
{ ,/
RELEASE OF LOAN PR(rcEEDS For Poli cy Loa n Only (Prt drer,k one)

LJ Pick up ! Mailto Region ! Deposit to ! Automatic Salary Deduction

fI Over-thecounter payrnent
This is to authorize Public Safety Mutual Benefit Fund, lnc. to credit proceeds of my loan to: E Deduaion from loan proceeds
o Name of bank Account number ! Charged to Equity Value upon terminatirn of nrembership
. Others:
BORROWER'S DATA
RANK I.AST NAME FIRST NAME MIDDLE NAME OF BIRTH PAYSUP NO.
{ { { { { {
NAME OF AGENCY UNIT TIN
/ ,/ { /
DATE ENTERED SERVICE RET]REMENT DATE TELEPHONE NO. RIGHTTHUMB
/
PERMANENT ADDRESS EMA]L ADDRESS
/
NAME OF SPOUSE
{
SIGNATURE OF BORROWER
,/
GOiIPLIANGE TO CRED]T INFORHATION SYSTEM
ln compliance, PSMBFI will submit your basic credit data as well as any regular updates or conection thereof to the Credit lnformation Corporation (ClC)
for consolidathn and disdcur€ as may be authodzed by ClC. Sucfi credit data may be shared by CIC with other authqized lenders d olher duly
accEdited rcpoding agencies tur lhs purposs of estaHishing your ctBdit worltiness-

Signature over Printed Name of Bonower

AUTHORIZATION TO DEDUCT (For PNP Only)
Please e to Dductfor oilrcr
hereby authorize PNP Finance Service FS) to ded uct from my salary/retirement benefits/commutation of credits/pension and pay the
sum of (P________J every month for months beginning for
payment of my loan amortizations until full settlement thereof with PUBLIC SAFETY MUTUAL BENEFIT FUND, NC. (PSMBFT)_ further authorize
PSMBFI to access my personal infomation under my Uniuoffca Glectonic paymll system.

ln case of disrissal, E6ignatim, separation, voluntary oa compdsqy retirern€nt or Eminalion horn tle ssrvic€ lor Yrh&!,s. car6e, l, as the
boflqver shall pay the q&iarding rsmai ng balance, irrcluding inter€6t, co6b, finss, f€€6, penalties, and other chargss to PSMBFI fom any and all pay
and b€nefib due me or legal h€ils ftom my untimoly dsath.
I hsreby expessly waive all my rights under S€ction 13 Ruls 39 of the Rul€s of Court. R€puHic Act No6..675 (PNP Law), 4917 (Retirement
Benefib of Emploi?eg; ot fiivatq fims),-gSiO (Crcdit lnformation System), '10173 (Data PrivEy), and to any and all statutory plovbirE rdating b rhe
confider iality of intomation.
I fully understand that the loan obligation is a contract between the PSMlBFl and the undersigned bonower and thus, heteby etssume all the
obligation that may arise thereof and hereby understand the PNP FS is not privy to the contlrct of loan executed with PSMBH, hn is rnerely authorized
pursuant to GAA to deduct loan obligation/s ftom the salaries of employees/retirees.
Thumbrnarks

{
Signature over Printed Name of Bonower

Subscribed and swom to before me the day at Philippines.

Doc. No.
Page No- -
Book No.
Series of
DO NOT WRITE THIS LINE
PRINCIPAL
OUTSTANDING BALANCE
NET PROCEEDS
MONTHLY AMORTIZATION

LOAN NO. VOUCHER NO

EVALUATED
REVIEWED/CHECKED BY
 PROTS SORRY NOTE/LOAN AGREEMENT

KNOW ALL MEN BY THESE PRESENT:

ln consk eration of the loan received ftom PUBLIC SAFETY MUTUAL BENEFIT FUND, lNC., I hereby
acknowledge the folloiving:

1. Principal Amount
Loan Term
Monthly Amortization

2. As security of this loan, I hereby assign all rights and interest on my Equity Plan Certmcate of
Membership as member of PSMBFI, up to the extent of loan balance.

3. All indebtedness under this loan shall become due and payable, and the Equity Value can be used to pay
off the indebtedness in case of:

a) Death of the member;

b) Retirement or discharge from the service/employment from the organization;
c) Voluntary termination of membership;
d) Dismissal with or without cause from service;
e) AWOL; and
0 Any reason, in which event the total amount of loan plus interest shall be deducted from any benefits
from PSMBFI.

4. lf for any reason, the agency/organization to which I am receiving my salary is unable to deduct the
monthly arnortization from my salary, I shall immediately remiupay direcfly the monthly amortization to
PSMBFI ffice. Otherwise, the unpaid installment shall eam interest at additional rate of Yo and
shall continue accruing interest until fully paid.

5. Pr6.termination of loan shall be subject to a fee equivalent to five (5%) percent of the pdncipal balance
plus any unpaid interest.

6. ln case of separation from the service for whatever cause, the unpaid balance, including its accumulated
interest and surcharges as stipulated above, shall be deducted ftom my last paynent, commutation of
leaves, pension and all other separation benefits and thereby waive my rights under applicable rules.

7. ESCALATION CLAUSE PENALTIES ATTORNEY'S FEES, COST & VENUE. ln case of non-payment of
two (2) successive installments, the whole sum shall become immediately due and payable without need
of demand or notice, and I agree to pay by way of cash or deduction ftom my Equity Value as penalty
charges an additional amount equivalent to ( %) percent per annum of the
total amount due, until fully paid and %) of the total amount due as
attomey's fees plus cost of suit and other litigation expenses. Proper courts in San Juan City, Philippines
shall be exclusive venue of any suit arising from this agreement.

,/
Signature over Printed Name of Borower
 DEED OF UNDERTAKING
(Author zat on to Deduct)

t{ of legal age, Filipino citizen,

single/manied, and with postal address at { after
having been duly sworn to in accordance with the law hereby depose and state that:

1. I am a member of the Philippine National Police (PNP) cunently assigned at

{
2. I obtain a loan from PUBLIC SAFETY MUTUAL BENEFIT FUND, lNC. (PSMBFI)
payable by way of automatic salary deduction from my monthly salary;

3. I hereby acknowledge that upon retirement (compulsory or optional), resignation

from service, TPPD, or any other cause for severance from service, the
monthly amortizations for the loan can no longer be deducted from my monthly
salary, thus, I undertake to pay the outstanding balance of the said loan, if any,
at the time of severance from service;

4. At the time of severance from service, I further authorize the Philippine National
Police, in particular, the Retirement Claims and Funds Management Division,
(RCFMD) and/or Pension and Gratuity Division (PGD) of PNP Retirement and
Benefits Administration Service (PRBS), or Directorate for Finance, as the ffise
maybe, to deduct the outstanding balance as of retirement date due to PSMBF!,
from my Commutation of Accumulated Leave (CAL) claims and Lump
Sum/Retirement Gratuity claims and monthly pension;

5. I am executing this Deed of Undertaking (Authorization of Deduct) voluntarily,

without force or intimidation, and solely for the purpose of payment of my
outstanding obligation with PSMBFI, if any, at the time of severance from service
from the Philippine National Police;

6. I further attest to the truth of the foregoing statements.

!N WITNESS WHEREOF, I have affixed my hand and signature this

day of tn

S GNATURE OVER PR NTED NAiiE

SUBSCRIBED AND SWORN TO BEFORE ME this day of

affiant exhibiting his Government lssued lD No.
bearing his photograph and signature as competent proof of identification.

Doc. No._
Page No--
Book No._
Series of
Republic of the Philippines)
) S.s

SPEC AL POWER OF ATTORNEY

l, { , of legal age, Filipino citizen, with

postal address in { , after
having been duly sworn to in accordance with law, hereby execute this special power of attorney in
favor of PHILIPPINE NATIONAL POLICE (PNP) in particular:

a. PNP DIRECTORATE FOR FINANCE;

b. PNP RETIREMENT AND BENEFITS ADMINISTRATION SERVICE (PNP PRBS);
C. RETIREMENT CLAIMS AND FUNDS MANAGEMENT DIVISION (PNP PRBS RCFMD); and
d. PENSTON AND GRATUTTY DTVTSTON (PNP PRBS PGD)

to do and perform the following acts for and on my behalf:

1. I attest that during my employment with the PNP, I obtained a loan from PSMBFI and which at
the time of my separation from service (death, dismissal, resignation, voluntary or compulsory
retirement, termination, or for whatever cause/reason) remains unpaid. At the time of my
separation from service from the PNP, I hereby authorize any of these Offices to deduct from
my Commutation of Accumulated Leave (CAL), Lump Sum/Retirement Benefits, and Pension,
any and all outstanding obligation I have incurred in favor of PUBLIC SAFETY MUTUAL
BENEFIT FUND, tNC. (PSMBF!);

2. I am executing this power of attomey voluntarily, without force and intimidation, for the purpose
of informing these Offices that I have fully, freely, and voluntarily authorized them to deduct my
PSMBFI outstanding loan obligation from my Commutation of Accumulated Leave (CAL), Lump
Sum/Retirement Benefits, and Pension and consequently for the settlement of my loan
obligation with PSMBFI;

3. I further authorize any of these Offices to remit and directly pay to PSMBFI any amount
collected from Commutation of Accumulated Leave (CAL), Lump Sum/Retirement Benefits, and
Pension representing payment for my loan obligation.

lN WITNESS WHEREOF, I have affixed my signature this day of

tn

,/
SIGNATURE OVER PR NTED NAME

ACKNOWLEDGEMENT

BEFORE ME personally appeared acknowledging that he/she

voluntarily executed the foregoing document and known to me the same person who executed the
same, exhibiting his/her government issued lD valid until
bearing his/her photograph and signature as competent proof of identification.

Notary Public

Doc. No.
Page No._
Book No.
Series of
 CRED T L FE NSURANCE APPL CAT ON FORM

MEMBER-BORROWER INFORMATION
Last Name First Name Middle Name Qualifier k unt No

CivilStatus: Date of Birth lace of Birth

P nt Assignment (Unit & Region) one No

nent Home Address elephone No

TIN/SSS/GSIS: Valid lD No. Source of Funds:

IOAN PARTICULARS
Status of Loan Payment Terms
New Loan I Re-Loan !
Amount in Words Peso Value

TO BE FILLED UP BY PSMBFISTAFF
CLI Premium Amount of Coverage: Effective Date: Termination Date

I hereby declare that all foregoing answers and statements are complete, true and correct. I hereby agree that if there be any fraud or misrepresentation in the
above statement material to the risk, PSMBFI, upon discovery within six months from the effective date of insurance, shall have the right to declare such
nulland void.
i;urance
Signature of M ember-Borrower

FS*SFt
PUBL C SAFETY MUTUAL BENEF T FUND, NC.
No. 3L8-320 Santolan Rd., cor. 1't and 2nd West Streets, San Juan City, Metro Manila
Tel. No. 7 25-L67 5 ; 7 26-aO7 O ; Telefax No. 7 26 -7 25O
Tl N No. 2OO-568-485-O00O; ema il :customerca re@ psm bf i.com' ph
r*a?

CD IFI F' C D IT LIF'D INST] CE

Certificate No Effective Date:

This is to certifu that

(lYame of Member-Borrower)

of death The CLI coverage shall follow the term

is insured to the extent of his/her outstanding loan balance at the time
of the loan, which ceases in of Termination as specified in section 12 of the Mastet Policy contract' This
case
Life Insurance of
certific(Ite is issued under and subject to the provisions of the Master Policy Confuact for Credit

Public Safety Muaal Benefit Fund, Incorporated'

herclo affixed its seal and caused this Certificate to be signed by the President at ils
In witness hereof, the PSMBFI has

Main Ofice in San Juan City, Meto Manila'

PRESIDENT