7/28/2019 Rebuttal for Real Estate call in

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REASON FOR CLAIM (Check appropriate box)

APPLICATION FOR PROVIDENT

BENEFITS (APB) CLAIM

HQP·PFF ·040

APPLICATIONNo. J

'--~

...•.. " . . . . . "

o MEMBERSHIP MATURITY

o OPTIONAL WITHDRAWAL

o RETIREMENT

Effective Date ofRetirement _

Last Day of Service========

o SEPARATION FROM SERVICE DUE

TO HEALTH REASONS

o TOTAL DISABILlTYIiNSANITY

Nature of Illness _

o PERMANENT DEPARTURE FROM

THE COUNTRY

o DEATHDate ofDeath _

o OTHERS

Please Specify _

o MODIFIED Pag-IBIG II (MP2) 0 Pag-IBIG OVERSEAS PROGRAM (POP)

•••••••••• Em~· . · ••••••••••••••LAST NAME FIRST NAME NAME EXTENSION (e.g., Jr., II) MIDDLE NAME Pag-IBIG MID NoJ RTN

CLAIMANT, if other than Member (Last Name, F irs t Name, Name Extension, Middle Name RELATIONSHIP TO MEMBER

DATE OF BIRTH (mm/dd/yyyy)

CONTACT DETAILS (Indicate country code if abroad)

COUNTRY +AREA CODE TELEPHONE NUMBER

Home

MOTHER'S LAST NAME BEFORE MARRIAGE (For Married Female Only)

MEMBER'S PRESENT HOME ADDRESS

Unit/Room No., Floor Building Name LotNo., Block No., Phase No. House No. Street Name

•

Barangay Municipality/City Province/State/Country (if abroad) ZIP Code 1 1 1 _

Cell Phone

Subdivision

Barangay Municipality/C ity Province/State/Country (if abroad) ZIP Code

1 1 1 _

Email Address

CLAIMANTS PRESENT HOME ADDRESS (Leave blank if the same as member)Unit/Room No., F loor Building Name Lot No., Block No., Phase No. House No. Street Name Subdivision

EMPLOYMENT HISTORY FROM DATE OF Pag-IBIG MEMBERSHIP (Use another sheet if necessary)

NAME OF EMPLOYER/BUSINESS ADDRESSDATE OF Pag-IBIG MEMBERSHIP

FROM (MonthlYear) I TO (MonthlYear)

IAUTHORITY TO CREDIT

AUTHORITY TO TRANSFER(For matured savin sunder Pa -IBIG II/Pag-IBIG Overseas Pro ram)

1 '----__ -

PAYROLL ACCOUNTIDISBURSEMENT I BANK'S ADDRESS

CARD NO.

MP2 ACCOUNT NO. I AMOUNT TO BE TRANSFERRED

o Full Amount 0Partial Amount P _

IN THE EVENT OF THE APPROVAL OF MY APPLICATION FOR PROVIDENT BENEFITS CLAIM, IHEREBY AUTHORIZE Pag-IBIG Fund TO CREDIT MY CLAIM PROCEEDS TO MY LANDBANKACCOUNT OR CASHCARDTHAT I HAVE INDICATEDBELOW

IN THE EVENT OF THE APPROVAL OF MY APPLICATION FOR PROVIDENT BENEFITSCLAIM, I HEREBYAUTHORIZE Pag-IBIG FundTO TRANSFER MY CLAIMPROCEEDS TO MYMP2ACCOUNTTHAT I HAVE INDICATEDBELOW

SIGNATURE OF MEMBER DATE SIGNATURE OF MEMBER DATE

APPLICATION AGREEMENT

LEFT THUMB RIGHT THUMB

I hereby certify that I have read andunderstood the contents hereof, including the guidelines and instructions indicated at the backportion ofthis form. I further certify under painof perjury that all information I have indicated herein are true and correctto thebestofmyknowledgeandbelief, and that my sig nature or thumbmark appearing herein is genuine and authentic. I l ikewise understand that t he processing of th is

application is subject to perti nent provisions of the implementing ru les and regulations of the Pag-IBIG Fund. In t he event o f any outs tanding

Pag -IBIG loan, Pag -IBIG Fund is hereby authorized to wi thhold, in whole or in part, the provident benefi t subject of this claim, and apply the

same as payment to the s aid loan as well as other ob ligations due to the Pag -IBIG Fund as o f t he d ate of this appl ication.

I hereby wai ve my rights under R.A. No. 1405 and authorize Pag-IBIG Fund to veri fy/validate my payrol l bank account number.

THUMB MARKS OF MEMBER/CLAIMANT

(I f unab le to sign)

MEMBERICLAIMANT

(Signature over Printed Name)

(Tobe done In the presence of Pag-IBIG Fund Personnel)

(Signature over Printed Name of Witness) Date

THIS PORTION IS FOR Pag -IB IG FUND USE ONLY

Pag-IBIG LOANS AVAILED DVNO. CHECK NO. OUTSTANDING BALANCE AS OF

PARTICULARS DETAILS

PROVIDENT BENEFITS CLAIM DV/CHECK NO. DATE FILED

HL ACCOUNT NO. TAKEOUT DATE OUTSTANDING BALANCE AS OF

MULTI-PURPOSE/CALAMITY LOAN

HOUSING LOAN

PAYEE/S REMARKS

COMPUTATION OF AMOUNT DUE TO MEMBER

DETAILS AMOUNTS PAYABLE REMARKS COMPUTED BY DATE

EMPLOYEE'S/MEMBER'S TOTAL CONTRIBUTION l'EMPLOYER'S TOTAL CONTRIBUTION

TOTAL DIVIDENDS EARNEDREVIEWED BY DATE

TOTAL ACCUMULATED VALUE (TAV) l'LESS: OUTSTANDING LOAN BALANCE

APPROVED BY DATE

I

NET AMOUNT l'DEATH BENEFIT

DISAPPROVED BY DATEI

I

TOTAL AMOUNT DUE TO MEMBER l'(t-cevtsea i tran. j

TH/S FORM MAY BE REPRODUCED. NOT FOR SALE

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