HQP-HLF-001

(V02, 05/2019)
APPLICATION FOR LOAN RESTRUCTURING
(Under R.A. 9679)

HOUSING ACCOUNT NO. Pag-IBIG MID Number/RTN

(PLEASE PRINT ALL ENTRIES IN BLOCK OR CAPITAL LETTERS)

RESTRUCTURING PARTICULARS
DESIRED LOAN TERM DESIRED RE-PRICING PERIOD (YEAR/S) MODE OF PAYMENT
 1  3  5  10  Salary deduction  Collecting Agent
 15  20  25  30  Over-the-Counter  Bank
 Post-Dated Checks  Developer
 Cash/Check Remittance Center
PRINCIPAL BORROWER’S DATA
LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME MAIDEN NAME
(e.g. Jr., II) (for married women only)

DATE OF BIRTH (mm/dd/yy) SEX CITIZENSHIP MARITAL STATUS

 MALE  Single/Unmarried  Legally Separated  Widow/er
 FEMALE  Married  Annulled/Divorced
PERMANENT HOME ADDRESS CONTACT DETAILS
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name (Indicate country code if abroad)
COUNTRY + AREA CODE TELEPHONE NO.
HOME TEL. NO.
Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code

BUSINESS TEL NO.

PRESENT HOME ADDRESS
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name
CELLPHONE NO.

Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code

E-MAIL ADDRESS

OCCUPATION
 Locally Employed  Self-Employed  Overseas Filipino Worker (OFW) TAXPAYERS IDENTIFICATION NO. (TIN)

EMPLOYER/BUSINESS NAME

SSS/GSIS ID NUMBER
EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name

PREFERRED MAILING ADDRESS

Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code  Permanent Home Address
 Present Address
 Employer/Business Address
LEGAL HEIR’S DATA
LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME MAIDEN NAME
(e.g. Jr., II) (for married women only)
Attach Here
1” x 1”
DATE OF BIRTH (mm/dd/yy) SEX CITIZENSHIP RELATION TO PRINCIPAL BORROWER MARITAL STATUS ID PHOTO
 Spouse  Parent
 MALE  Son/Daughter  Other (please specify)
 Single/Unmarried  Legally Separated
 Married  Annulled/Divorced
 FEMALE  Brother/Sister _________________  Widow/er

PERMANENT HOME ADDRESS CONTACT DETAILS

Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name (Indicate country code if abroad)
COUNTRY + AREA CODE TELEPHONE NO.
HOME TEL. NO.
Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code

BUSINESS TEL NO.

PRESENT HOME ADDRESS
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name
CELLPHONE NO.

Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code

E-MAIL ADDRESS

OCCUPATION
 Locally Employed  Self-Employed  Overseas Filipino Worker (OFW) TAXPAYERS IDENTIFICATION NO. (TIN)

EMPLOYER/BUSINESS NAME

SSS/GSIS ID NUMBER
EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name

PREFERRED MAILING ADDRESS

Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code  Permanent Home Address
 Present Address
 Employer/Business Address
 HQP-HLF-001
(V02, 05/2019)

CO-BORROWER’S DATA (1)

LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME MAIDEN NAME
(e.g. Jr., II) (for married women only)

Attach Here
DATE OF BIRTH (mm/dd/yy) SEX CITIZENSHIP RELATION TO PRINCIPAL BORROWER MARITAL STATUS 1” x 1”
 Spouse  Parent  Single/Unmarried  Legally Separated ID PHOTO
 MALE  Son/Daughter  Other (please specify)  Married  Annulled/Divorced
 FEMALE  Brother/Sister _________________  Widow/er
PERMANENT HOME ADDRESS CONTACT DETAILS
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name (Indicate country code if abroad)
COUNTRY + AREA CODE TELEPHONE NO.
HOME TEL. NO.
Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code

BUSINESS TEL NO.

PRESENT HOME ADDRESS
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name
CELLPHONE NO.

Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code

E-MAIL ADDRESS

OCCUPATION
 Locally Employed  Self-Employed  Overseas Filipino Worker (OFW) TAXPAYERS IDENTIFICATION NO. (TIN)
EMPLOYER/BUSINESS NAME

SSS/GSIS ID NUMBER
EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name
PREFERRED MAILING ADDRESS
Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code
 Permanent Home Address
 Present Address
 Employer/Business Address
CO-BORROWER’S DATA (2)
LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME MAIDEN NAME
(e.g. Jr., II) (for married women only)
Attach Here
1” x 1”
DATE OF BIRTH (mm/dd/yy) SEX CITIZENSHIP RELATION TO PRINCIPAL BORROWER MARITAL STATUS
 Spouse  Parent
ID PHOTO
 MALE  Son/Daughter  Other (please specify)
 Single/Unmarried  Legally Separated
 Married  Annulled/Divorced
 FEMALE  Brother/Sister _________________  Widow/er
PERMANENT HOME ADDRESS CONTACT DETAILS
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name (Indicate country code if abroad)
COUNTRY + AREA CODE TELEPHONE NO.
HOME TEL. NO.
Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code

BUSINESS TEL NO.

PRESENT HOME ADDRESS
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name
CELLPHONE NO.

Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code

E-MAIL ADDRESS
OCCUPATION
 Locally Employed  Self-Employed  Overseas Filipino Worker (OFW)
TAXPAYERS IDENTIFICATION NO. (TIN)
EMPLOYER/BUSINESS NAME

SSS/GSIS ID NUMBER
EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor Building Name Lot No., Blk No., Phase No., House No. Street Name
PREFERRED MAILING ADDRESS
Subdivision Barangay Municipality/City Province and State Country (if abroad) Zip Code  Permanent Home Address
 Present Address
 Employer/Business Address
CERTIFICATION
I/We certify that the foregoing information/statement is to my/our knowledge, true, correct, complete, and updated. The signature/s appearing above my/our printed
name/names below is/are genuine.

I/We authorize 1) Pag-IBIG Fund or its duly authorized representative to verify necessary information or data (i.e., certificate of employment, pay slips and income tax return)
with the concerned government agencies or third parties including banks and other financial institutions from whom Pag-IBIG Fund had obtained information; to regularly submit
and disclose my/our credit data (as defined under Republic Act No. 9510 and its Implementing Rules and Regulations) to Credit Information Corporation (CIC) as well as any
updates or corrections thereof; and to send me/us updates about my/our housing loan application/account via SMS/text, email, mail or other available means of communication;
and 2) CIC to share my/our credit data with accessing entities, special accessing entities, outsource entities and data subjects, in accordance with the Implementing Rules and
Regulations of Republic Act No. 9510.

I/We hereby further waive confidentiality rules and laws as applicable to establish correctness, validity, and authenticity of documents that would help facilitate the processing
and evaluation of my/our application.

I/We hereby agree that any misrepresentation of a material fact is a ground for disapproval of the application, cancellation of the loan, and shall be a cause for the total
outstanding obligation to be due and demandable and shall be subject to other sanctions provided in existing Pag-IBIG Fund guidelines. I/We agree to notify Pag-IBIG Fund of any
material change affecting the information contained herein. I/We agree that all information obtained by Pag-IBIG Fund shall remain its property whether or not the loan is granted.

I/We further agree to be bound by the current and general policies of Pag-IBIG Fund and those that the Pag-IBIG Fund may adopt in the future, that may have relation to or in
any way affect my/our loan.
I/We understand that should my application be approved, notarial and all other fees shall be for my/our account.

_______________________________ ____________ ____________________________________________ __________

SIGNATURE OF BORROWER DATE SIGNATURE OVER PRINTED NAME OF SPOUSE DATE

_______________________________ ____________ ____________________________________________ __________

SIGNATURE OF CO-BORROWER DATE SIGNATURE OVER PRINTED NAME OF SPOUSE DATE

_______________________________ ____________ ____________________________________________ __________

SIGNATURE OF CO-BORROWER DATE SIGNATURE OVER PRINTED NAME OF SPOUSE DATE

THIS FORM MAY BE REPRODUCED. NOT FOR SALE.