Republic of the Philippines

DEPARTMENT OF EDUCATION
Region V

Division of Camarines Sur

Freedom Sports Complex, San Jose Pili, Camarines Sur

APPLICATION FOR GSIS LOAN

Type of Loan Applied for REGULAR POLICY LOAN

NAME OF APPLICANT:
SERNAL SALGIE PANTON
Last Name First Name Middle Name
Birth Date: December 10, 1979 Age: 44
Residential Address: Zone 2, Laganac, Balatan, Camarines Sur
School Assignment: Laganac High School District: Balatan
Division/Station/Employee Number: 013/641/4780319
UMID CARD No. (The twelve digits number in your UMID Card): 000-1152-72-4
Have you applied for a GSIS Loan previously? Yes
If yes, type of loan applied: MULTI-PURPOSE LOAN Date of Application: 11/28/2023
Date of Original Appointment: July 18, 2014
Status of Employment: Permanent E-mail Address: salgie.sernal@deped.gov.ph
Cell Phone Number: 09298125087 Office/Home Number:
I hereby certify under oath that:
(1) I am in the service.
(2) I have no pending administrative case and/or criminal charge.
(3) The information supplied by the undersigned is true and correct.
(4) I am not on leave of absence without pay.
(5) As of November 2023 the following appears in my Pay Slip:
Gross Monthly Income: Php29, 865.00
Total Deductions: Php21, 270.67
Net take-home pay: Php8,594.33
(6) The monthly amortization shall be deducted from the monthly salary.
(7) In case of separation from the service of the borrower, clearance shall be obtained from the GSIS
before any document and/or final payment is released in my favor.

SALGIE P. SERNAL
(Signature over Printed Name of Borrower)
Date Signed: January 7, 2024

Attested:

DELIA S. SAYSON
(Signature above Printed Name of the School Head)
Date Signed:
Mobile Phone Number: