HQP-HLF-047

(V03, 03/2020)

APPLICATION FOR MORATORIUM ON HOUSING LOAN

AMORTIZATION PAYMENTS
(Please accomplish in two (2) copies)
Pag-IBIG MID Number/RTN

(PRINT ALL ENTRIES IN BLOCK OR CAPITAL LETTERS)

LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME AGE HOUSING ACCOUNT No. WITH PDC
WITHOUT PDC
PERMANENT HOME ADDRESS CONTACT DETAILS (indicate country code if abroad)
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name COUNTRY + AREA CODE TELEPHONE NUMBER
Home
Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code

Cell Phone
PRESENT HOME ADDRESS
Unit/Room No., Floor Building Name Lot No., Block No., Phase No., House No. Street Name

E-mail Address
Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code

EMPLOYER/BUSINESS NAME CONTACT DETAILS (indicate country code if abroad)

COUNTRY + AREA CODE TELEPHONE NUMBER
Business (Direct Line)
EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor Building Name Lot No., Block No., Phase No., House No. Street Name
Business (Trunk Line)

Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code Employer/Business Email Address

CERTIFICATION
I hereby certify, under pain of perjury that;
1. I am a victim of ______________________________; 5. I waive confidentiality rules and laws as applicable to establish correctness,
(Kind of Calamity) validity, and authenticity of documents that would help facilitate the processing
and evaluation of my application including the relevant employment/income
2. My house has been damaged source of income has been impaired due to information that shall be provided by my employer;
the said calamity; 6. My signature appearing herein is genuine and authentic; and
3. The information given and any or all statements made herein are true and correct 7. If Pag-IBIG Fund found out through verification that there is a falsification,
to the best of my knowledge and belief; misrepresentation or any similar acts committed by me, Pag-IBIG Fund shall
4. I authorize Pag-IBIG Fund to share my/our personal information and other details automatically disapprove my application and I shall pay Pag-IBIG Fund the
of my loan account with other government agencies and third parties, as may be housing loan amortization due with corresponding penalties. I shall abide with all
necessary in the management of my account/s and for collection purposes, applicable rules and regulations governing this moratorium that Pag-IBIG Fund
subject to the limits under Republic Act No. 10173 (Data Privacy Act of 2012), may promulgate from time to time.
and its Implementing Rules and Regulations. Further, I promise to notify Pag-IBIG
Fund of any amendments or changes in my personal information indicated herein;

__________________________________ ____________
Signature of Applicant Over Printed Name Date

EMPLOYER/BARANGAY CERTIFICATION

This is to certify that Mr./Ms. ___________________________________________ with residence address at ________________

__________________________________________________________________ was affected by ___________________. (Kind of Calamity) It is
further certified that his/her  house has been damaged/  source of income has been impaired by the said calamity.

This Certification is being issued in relation to the application for moratorium of the above-mentioned Pag-IBIG Fund member.

Issued this ______ day of ________________ at ____________________________________________________________.

_________________________________________________ ______________________________________________
HEAD OF OFFICE OR AUTHORIZED REPRESENTATIVE/ DESIGNATION/POSITION
HEAD OF BARANGAY
(Signature Over Printed Name)

THIS PORTION IS FOR Pag-IBIG FUND USE ONLY

DATE FILED: ________________ PROOF OF DAMAGED PROPERTY/AFFECTED REMARKS

SOURCE OF INCOME
 WITHIN PRESCRIBED PERIOD
 WITH PICTURE  WITHOUT PICTURE
 BEYOND PRESCRIBED PERIOD
ADDRESS WITHIN AREAS DECLARED UNDER HOUSE DAMAGED/SOURCE OF INCOME
STATE OF CALAMITY IMPAIRED BY CALAMITY
 YES  NO  YES  NO
STATUS OF ACCOUNT AS OF ______________ AGE UPON MATURITY CHECKED BY: DATE

 UPDATED  IN ARREARS  WITHIN 70  BEYOND 70

REMARKS ON INSPECTION DATE INSPECTED INSPECTED BY: DATE

APPROVED BY: DATE DISAPPROVED BY: DATE REMARKS