Membership No. ____________________ Mobile No.

: ______________________
Email address: _____________________ Activation Code: __________________

SWORN DECLARATIONS AND UNDERTAKING

RELATING TO ENROLLMENT IN THE PSSLAI
MOBILE SERVICES SYSTEM (MSS)

I, _______________________________, Filipino, of legal age, single/ married, and a bona fide member of the Public Safety Savings and Loan Association, Inc. (PSSLAI),
under oath, hereby declare:

1. I possess the legal capacity to execute this instrument and I am not suffering from any incapacity under the law;
2. I have enrolled in the Mobile Services System (MSS) of the PSSLAI through registration of my identical 10-digit SIM (Subscriber Identity Module) number ______________,
which will serve as my user identification under the MSS;
3. I understand and agree that the MSS is a facility granted by the PSSLAI which I may avail of for as long as it is offered and provided that I continue to be qualified under its
terms and conditions. I likewise understand and agree that under its terms and upon my violation or breach of the same as well as those of my undertakings herein, my use,
access and/or availment of the MSS may be suspended, cancelled or revoked by the PSSLAI at anytime;
4. Before enrolling in the MSS and executing this Sworn Undertaking in relation to the same, I confirm that I had been apprised of and had fully informed myself of the terms,
mechanics and workings of the MSS as well as the benefits and risks of enrolling in, availing of and/or using the same, including the applicable charges corresponding to each
service;
5. I likewise confirm that before enrolling in the MSS and executing this Sworn Undertaking in relation to the same, I was given sufficient time to study the terms of both as well as
to seek the advice of advisers and/or counsel regarding the same;
6. I understand and agree that services under the MSS shall be limited to:
a. Balance inquiry of my account;
b. Request for fund transfer from one PSSLAI deposit account to another PSSLAI deposit account;
c. Request for fund transfer from PSSLAI deposit account to the PNB ATM account;
d. Loan application and renewal;
e. Inquiry into loan renewal balances from various loan facilities of the PSSLAI;
f. Request for Prepaid Load from any PSSLAI deposit account;
g. Pre-purchase of other non-core transactions of the PSSLAI such as the healthcard, etc.;
h. Remittance through the FUNDALA program; and
i. Payment of bills through the Bills Payment Facility.
7. I understand and agree that all information, transactions and data relating to my account, deposit and/or investments which are facilitated, transmitted, coursed through,
conveyed and/or recorded through the MSS as well as my SIM card and PIN for the purpose (hereafter collectively referred to as the “Information”) are highly confidential in
nature and that it is my sole responsibility to ensure the confidentiality and security of the Information thus I undertake to observe extraordinary diligence in protecting/securing
the Information from third parties including the Government and its offices, agencies or instrumentalities as well as the courts of law and officials, employees and agents of the
latter;
8. I likewise understand that the Information is covered by bank secrecy laws of the Philippines as well as by Section 6 of Republic Act No. 8367 (The Revised Non-Stock
Savings And Loan Associations Act of 1997) and those of Section 4652S (Confidential Information) of the Regulations Governing Non-Stock and Savings and Loan
Associations under the Manual of Regulations For Non-Bank Financial Institutions issued by the Bangko Sentral ng Pilipinas (BSP) thus I expressly undertake not to disclose
or divulge the Information or any portion thereof to third parties including the Government and its offices, agencies or instrumentalities as well as any court of law and officials,
employees and agents of the latter without coordinating with the PSSLAI and securing its written consent to such disclosure;
9. I hereby accept full responsibility and accountability for all instructions under the MSS that come from and/or are executed via my 10-digit SIM number and I understand that
the PSSLAI shall consider as lawful, valid and binding upon myself and the Association any instruction or transaction made and/or coming from the identical 10-digit number
corresponding to the SIM card registered under my account under the MSS and that the PSSLAI shall not be obliged to investigate the authenticity of the instructions bearing
my said 10-digit SIM number. I understand and agree, however, that the PSSLAI may, if it deems necessary, verify any such instructions with me via telephone or any other
means;
10. I expressly undertake to hold the PSSLAI or any of its officers, employees, agents or assigns free and harmless from any liability, charges or obligation arising from my
enrolment in, availment of and use of the MSS as well as from any unauthorized action or transaction coming from the identical 10-digit SIM number registered under my
account in the MSS;
11. I likewise expressly undertake to hold the PSSLAI or any of its officers, employees, agents or assigns free and harmless from any liability, charges or obligation arising from the
use of Information under the MSS as well as the disclosure, upon intentional or unintentional causes, of the Information or any portion thereof to third parties;
12. In connection with my enrolment in and availment of the MSS, I hereby authorize the PSSLAI or any of its officers, employees and/or agents to examine my mobile device as
well as all my transactions under the MSS, including those with the telecommunications company involved and/or the National Telecommunications Commission (NTC),
whenever such are relevant, for verification, records reconciliation and audit purposes or whenever such is necessary to improve services under the MSS or to troubleshoot
and/or correct or attend to any error, malfunction or complaint by me relating to my availment and use of the MSS hereafter, the “Examination”). For the said purpose, I
expressly undertake to hold the PSSLAI or any of its officers, employees and/or agents free and harmless from any liability, charges or obligation for official actions in
connection with the Examination;
13. I understand and agree that the PSSLAI may cancel and/or refuse to execute any of my instructions via the MSS at any time, without prior notice, without the PSSLAI incurring
any liability, if such instructions are, as evaluated by the PSSLAI, against the law or regulations, or detrimental to the Association;
14. I expressly undertake to make use of the MSS solely for lawful purposes and transactions; and
15. I understand that I should appear at any offices of the PSSLAI to sign a new agreement every four (4) years.
16. I declare that I have read this document and have fully understood its contents after the same had been explained to me in the vernacular. I further declare that I voluntarily
and willingly executed this sworn document with full knowledge of my rights under the law.
17. I hereby disclose my SDLIS Username and SDLIS Password for all purposes covered by this undertaking.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of ______ 2014 at ______________, Philippines.

(Printed Name of Member)

PSSLAI ID No. _______________
Issued on ___________________
Valid until ___________________
Member since ________________

Witnessed by:

(Signature over printed name) (Signature over printed name)

ACKNOWLEDGMENT

BEFORE ME, a Notary Public for _________________, this ______day of __________, 20_______, personally appeared the foregoing with their current identification
documents issued by an official agency/Philippine government office bearing their photographs and signatures as indicated below their names shown above as competent proofs of their
identities, both known to me to be the same persons who executed the foregoing Agreement and they acknowledged to me that the same is their free and voluntary act and deed.

IN WITNESS WHEREOF, I set my hand and seal on the date and place above-written.

Notary Public
Notarial Commission No. ___________
Commissioned in__________________
Office Address____________________
________________________________
________________________________
My Commission expires on _________
________________________________
Doc. No. _______
Page No. _______
Book No. _______
Series of 2014.

AUTHORIZATION FOR DEDUCTION AND REMITTANCE FINANCE AUTHORIZATION and AUTOMATIC SALARY DEDUCTION FORM
(DEED OF UNDERTAKING)

To whom it may concern: To whom it may concern:

I, __________________________________________________________________ a member of PNP/__________ (Branch of
Service) and a loan applicant of Public Safety Savings and Loan Association, Inc. (PSSLAI), do hereby
authorize the ________________________________ to deduct from my monthly payroll / monthly pension /
retirement benefits / commutation of leaves and pay the amount of
(Php_________________________________) ___________________________________________________________________________
until my loan obligation is fully paid. This authorization shall not be rescinded or revoked without the
written approval of PSSLAI. If this authorization is not timely effected on my behalf, I shall pay the unpaid
amount and/or penalties thereof.
This will likewise serve as an authorization for the ____________________ to release in favour of PSSLAI
whatever amount due to them in case of separation, dismissal, resignation, termination and other causes
not herein mentioned whatsoever. I am allowing the PNP/__________ (Branch of Service) to deduct more
than the allowed percentage of benefits that can be remitted as payment for any liabilities incurred by me.
We concur that PSSLAI shall be given first priority in any benefit we will receive against any loan obligation
from other institution. This authority shall be in full force until my loan is fully paid. It does not relieve me of
my obligation to ensure that the deductions are made from my salary/ pension/other benefits and remitted
to PSSLAI.
Pursuant to Republic Act 8792 otherwise known as the E-Commerce Act of 2000 in relation to Republic Act
8367 otherwise known as the Revised Non-Stock Savings and Loan Association Act of 1007, by availing of
loan from PSSLAI through its electronic data facilities, that by virtue of the nature of this transaction, one
being constituted upon electronic means and/or computer generated, I fully understand that NO PHYSICAL
SIGNATURE may be required of me but my agreement of the terms and conditions governing the loan is
sufficiently manifested by the fact of my use of the electronic/computerized loan facility provided by
PSSLAI. A digital/ electronic signature may be provided evidencing my full agreement and consent to this
transaction.
I, _______________________________ a member of the PNP/__________ (Branch of Service) presently assigned at
_____________________________, do hereby execute this authorization to undertake the following:
 Authorize the PNP/__________ (Branch of Service) Finance Service to deduct from my payroll the amount
of Php1,100.00 beginning _______________, 20_____ as my Capital Contribution to be credited to my
account representing initial deposit and payment for Membership and ID fee.
 Authorize the Finance Service to deduct from my payroll account the amount of Php __________________
every month beginning _____________, 20_______ as my monthly Contribution /deposit in my
CAPCON PSA CASA with Account number ___________________________.
 Stop my CAPCON PSA CASA with Account number ___________________________.
 Adjust my monthly CAPCON PSA CASA with Account number _____________________.
From Php ______________________ to Php _________________________.
In addition, I/We hereby authorize the PNP/__________ (Branch of Service) Finance Service to collect/ deduct
from our salaries and/or benefits in accordance with the terms and conditions of the Promissory Note
which may go down to an amount of: ___________________________________________________________________until
the loan plus interest, fines, costs and other expenses are fully paid.
This will likewise serve as an authorization for the PNP/__________ (Branch of Service) Finance Service to
release in favour of PSSLAI whatever amount due PSSLAI in case of separation, dismissal, resignation,
termination from service for whatever cause, or underpayments resulting from my own fault/negligence.
PSSLAI will receive whatever benefits are due us from the PNP/__________ (Branch of Service) equivalent to
the total amount we owe PSSLAI. We concur that PSSLAI shall be given first priority in any benefit we will
receive from the PNP/__________ (Branch of Service).

BORROWER’S SIGNATURE OVER PRINTED NAME As Co-maker, it is understood that in case of default by the borrower as a result of separation or dismissal, I
am authorizing PNP/__________ (Branch of Service) Finance to release and/or deduct in favour of PSSLAI
ACKNOWLEDGEMENT whatever amount is due to PSSLAI from whatever benefits due me.
BEFORE ME, a Notary Public for _________________, this ______day of __________, 20_______, personally
appeared who exhibited to me his/her competent evidence of identification (CEI) the details of which are
provided next to their names as follows: MAKER’s SIGNATURE OVER PRINTED NAME
NAME ___________________________________________________ CEI PRESENTED ______________________________________
ISSUED AT __________________________________ ON ______________________________________ VALID UNTIL
____________________________________ CO-MAKER’s SIGNATURE OVER PRINTED NAME CO-MAKER’s SIGNATURE OVER PRINTED NAME
Known to me to be the same persons who executed the foregoing instrument and acknowledged to me
that the same is his free and voluntary act and deed.
WITNESS MY HAND AND SEAL at the place and on the date first mentioned.
Doc. No. ___________
Page No. ___________
Book No. ___________
Series of 2014.