Office of the President

NATIONAL HOUSING AUTHORITY 2x2 picture

Region 1 & CAR 1 Office

APPLICATION FORM
Control No.: ____________
THE GENERAL MANAGER
NHA Cmpd., Diliman, Quezon City

Sir:

In accordance with NHA Rules and Regulations and provisions of RA 7279 which I and my family agree to comply with faithfuly, I am hereby applying to purchase/rent:

Project :
Type of package (check one) : House/Unit only Lot only House and lot
Mode of payment (check one) Cash Installment: Years

A. APPLICANT INFORMATION
NAME BIRTH DATE(mm__/dd__/yyyy____)
(Maiden name for female applicants) Last Name Given Name Middle Name Extn. AGE

NAME OF SPOUSE BIRTH DATE(mm__/dd__/yyyy____)

(If applicable; maiden name, if wife) Last Name Given Name Middle Name Extn. AGE
ADDRESS
Street Barangay City/Municipality Province
CIVIL STATUS (Pls. Check) Single : Widow/er : HIGHEST EDUCATIONAL ATTAINMENT (Check one)
Married : Solo Parent: Post-grad.: Undergrad. Graduate
Separated : legally? Yes ____ No ____ College: Undergrad. Graduate
Others (specify) : High School: Undergrad. Graduate
Elementary: Undergrad. Graduate
COMMUNITY TAX CERT. NO. ISSUED ON ISSUED AT
B. EMPLOYMENT DETAILS
EMPLOYER
POSITION
EMPLOYMENT TYPE (Pls. Check) EMPLOYMENT STATUS (Pls. check)
Unemployed Regular
Government Contractual
Private Other (specify):
Self-employed (specify)
MEMBERSHIP (Pls. check) GSIS PAG-IBIG
SSS Other (Specify)

SPOUSE'S OCCUPATION SPOUSE'S EMPLOYER

C. APPLICANT'S FAMILY COMPOSITION
Name Relation to Applicant Civil Status Age Working? (yes/no) Income share (if applicable)
____________________________________ ___________________ _______ _______ _____________ _____________________
____________________________________ ___________________ _______ _______ _____________ _____________________
____________________________________ ___________________ _______ _______ _____________ _____________________
____________________________________ ___________________ _______ _______ _____________ _____________________
TOTAL:
D. INCOME DETAILS
APPLICANT'S TOTAL FAMILY INCOME PER MONTH PHP_______________ APPLICANT'S FAMILY EXPENSES PER MONTH PHP _______________
OTHER SOURCES OF INCOME
Source Ave. Monthly Income from Other Source
1 Php
2 Php
TOTAL Php
E. FAMILY REAL PROPERTY HOLDINGS
I and my wife (pls. check):
( ) Do not own nor under contract to buy any lot/dwelling unit in the Philippines.
( ) Own or under ontract to buy the following lots/dwelling units:
Urban Residential Total Area (sq.m.)
Commercial & Idustrial Total Market Value Php _________________
F. CERTIFICATION

A. I and my family have never availed of any government housing assistance/accommodation, nor violated Section 14 of Republic Act 7279: Urban
Development and Housing Act.

B. That I am not a professional squatter nor a member of a squatting syndicate.

I hereby certify that I am making this application for the purpose of acquiring a homelot for my family and not as a DUMMY or AGENT of
any other party.

Any false statement given by me hereinabove shall be sufficient cause for the forfeiture of all my priviledges and the CANCELLATION of
my contract executed by NHA pursuant to my application without prejudice to any administrative, criminal, or civil action that may be
brought by the NHA against me in accordance with existing laws.

_________________________________ _________________________________
Signature of Applicant Signature of Spouse
Contact Number

SUBSCRIBED and SWORN before me in _________________________________, Philippines this ____ day of ____________________,
20___. AFFIANT having exhibited to me his/her COMMUNITY TAX CERTIFICATE as stated above.

NOTARY PUBLIC
Doc. No. ;
Page No. ;
Book No. ;
Series of 20____