HQP-PFF-039

FOR HDMF USE ONI-Y

MEMBER'S DATA FORM (MDF)

INSTRUCTIONS Accomplish this form in two (2) copies. Type or print all entries in BLOCK or CAPITAL LETTERS. The "NAME EXTENSION" shall refer to JR., II, III and the like. Indicate the full name of your FATHER and MOTHER as they appear in your birth certificate. 5. Accomplish only the "PERMANENT HOME ADDRESS" if it is different with the "PRESENT HOME ADDRESS". 6. On the "CONTACT DETAILS" portion, indicate at least one (1) contact number. 1. 2. 3. 4.

PaQ-IBIGMID NUMBER
I I I I I I I I I II I I I I

REGISTRATION TRACKING NUMBER

7. On the "OCCUPATION' portion, indicate occupation based on the provided List of Occupation. 8. All fields which are marked with asterisk (*) are mandatory. 9. On the "HEIRS" portion, the provision on the Intestate Succession, as provided in the New Family Code shall be observed. a. SINGLE - Mother, Father, Brother and/or Sister b. MARRIED - Spouse, Son, Daughter, Mother and Father 10. For any subsequent change of information, please secure and accomplish two (2) copies of the Member's Change of Information Form (MCIF, [HQP-PFF-049]) and submit to the concerned Pag-IBIG Branch.

*MEMBERSHI~EGORY .MANDATORY

o o o

EMPLOYED PRIVATE EMPLOYED GOVERNMENT EMPLOYED PRIVATE HOUSEHOLD

o OVERSEAS FILIPINO WORKER (OFW) o SELFEMPLOYED (SE) o OTHER WORKING GROUP (OWG)
,
.FIRSTNAME

VOLUNTARY o EMPLOYED o INDIVIDUAL PAYOR (IP) o OTHER WORKING GROUP (OWG, if income is less than P1,OOO.OO) NAME EXTENSION
(e.g. Jr., II)

LAST NAME
I' ',i' -

MIDDLE NAME

NO MIDDLE NAME
(check if applicable only)

'MEMBER FATHER 'MOTHER 'SPOUSE

(Maiden Name)

D 0 D 0 0
'MARITAL STATUS

(If Married)

MEMBER'S NAME AS APPEARING IN THE BIRTH CERTIFICATE *DATE OF BIRTH

I I
m m

11
d d

I 'I
y

I
y y

I I
y

o Single/Unmarried o Married
CITIZENSHIP

0 Widow/er
D Legally Separated

o Annulled

TAXPAYERS

IDENTIFICATION

NUMBER !TIN)
I

I I I I I I I I I I I
SSS/GSIS
I I

*PLACE OF BIRTH
(CitylMunicipalilylProvince/Counlry) (Please indicate country if born outside the Philippines)

NUMBER
I

I I I I I I
NUMBER

I I I
No.

EMPLOYEE PROMINENT DISTINGUISHING FACIAL FEATURES

(Ex. Moles, Scars, etc.)
I

*SEX D Male D Female COMMON

(If Availab/e)
I I I I I

HEIGHT __ (m)

WEIGHT __ (kg)

I I I I I I I I I I I I
Code-Station Code

~serial/Badge

REFERENCE

NUMBER (CRN)

FREQUENCY
(If payment

OF MC PAYMENT
is not thru payroll deduction)

of contribution

o Monthly
I I I I I I I II

o Semi-Annually
AND CONTACT DETAILS Subdivision ZIP Code
(Indicate country code if abroad) TELEPHONE COUNTRY + AREA CODE NUMBER

D Quarterly ADDRESS

PRESENT HOME ADDRESS Unit/Room No., Floor Building Name Barangay MunicipalitylCity

Lot No., Block No., Phase No. House No Province/State/Country (if abroad)

Street Name

Home

I
*Cell Phone

I I I I I I I
Local

I I I

*PERMANENT HOME ADDRESS Building Name Unit/Room No., Floor Barangay MunicipalitylCity

Lot No., Block No., Phase No. House No Province/State/Country (if abroad)

Street Name

Subdivision ZIP Code

Business (Direct Line)

Business (Trunk Line)

'PREFERRED

MAILING ADDRESS D Permanent Home Address

I
o
Employer/Business Address

I I

I
I
(Revised 0812012)

Email Address

D Present Home Address

THIS FORM MA Y BE REPRODUCED. NOT FOR SALE.

MONTHLY Basic 'EMPLOYER/BUSINESS UriiVRoom No., Floor ADDRESS Building Name

INCOME
+

Allowances/Others Lot No., Block No., Phase No. House No. Tota/ Mo. Income

Street Name

Subdivision

Barangay

'TYPE

OF WORK (For OFWs only) 0 Sea-based

OLand-based . Municipality/City Province State/Country (If abroad) ZIP Code OFFICE ASSIGNMENT

o Head
'OCCUPATION 'FROM

Office

o Branch
TO
y

ITI!IOJ CITIITIIJ
y

EMPLOYER/BUSINESS

NAME

OFFICE ASSIGNMENT

o Head
EMPLOYER/BUSINESS ADDRESS FROM

Office

o Branch

[]]![llI] m m
EMPLOYER/BUSINESS NAME OFFICE ASSIGNMENT

ITIIill
m m

TO

o
EMPLOYER/BUSINESS ADDRESS

Head Office

Branch

FROM

TO

ITTIDIIJ~
m m
EMPLOYER/BUSINESS NAME OFFICE ASSIGNMENT

o
EMPLOYER/BUSINESS ADDRESS

Head Office

o Branch
TO

FROM

ITI!IIIJ~
MIDDLE NAME

r--------------I---------------------------r------rr~~ o
o o

I HEREBY CERTIFY THAT THE INFORMATION GIVEN AND ALL STATEMENTS MADE HEREIN ARE TRUE AND CORRECT.

SIGNATURE OF MEMBER

DATE

DISCLA/MER: Membership registration with the Fund does not automatically qualify a Pag-IBIG member to avail of the Fund's various loan programs. A Pag-IBIG member must satisfy the eligibility requirements and comply with the documentary requirements, which is

subject to verification and approval.