Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION IV-A CALABRZON
GATE 2 KARANGALAN VILLAGE, CAINTA, RIZAL
DEPED PROVIDENT FUND
BORROWER CO-MAKER
(Last Name) (First Name) (M.I) (Last Name) (First Name) (M.I)
Present Address: Present Address:
Home Address: Home Address:
Date of Birth: Date of Birth:
School: School:
Division No.: Station No.: Division No.: Station No.:
Employee No.: TIN No.: Employee No.: TIN No.:
SPECIMEN SIGNATURE SPECIMEN SIGNATURE
Loan applied for: (Check one)
Regular Loan Calamity Loan Special Loan
APPLICATION AGREEMENT
I hereby apply for an emergency loan in the amount, and at the amortization stated below.
In consideration of the grant hereof I promise to pay all installments due and bind myself to the terms and
conditon of the loan. Accordingly, I hereby authorize the deductions of the monthly amortization from my salary
when due. Should I be separated from the service, I also hereby authorized the deduction in full of any unpaid
balance from my retirement/separation benefits.
EMERGENCY LOAN AMOUNT OF LOAN AMORTIZATION SCHEDULE
Date: Php
Signature of Borrower Signature of Co-maker
CERTIFICATION FOR EMERGENCY LOAN
I HEREBY CERTIFY that the proceeds of the above load shall be used as follows:
Signature of Borrower
AUTHORIZATION FOR SALARY DEDUCTION
Sir:
I HEREBY AUTHORIZED THE DEDUCTION from my salary the amount of ,
(Php ) every month for months starting on 20 or until
my total loan of Php (P ) has bee paid.
Amount/s deducted shall be credited to the amount of the DEPED PROVIDENT FUND as amortization
on said loan.
(Div.No.) (Stn No.) (Emp. No.) (Signature Over Printed Name)
/
(Designation/ Position) (Division) (Province)
CERTIFICATE OF EMPLYOMENT AND CREDIBILITY
OFFICE: DATE:
THIS OFFICE CERTIFIES that: (1) The above applicant is a permanent employeeof this Office and is not on
leave of absence without pay; (2) there is no pending administrative/criminal charge againts him/her (3) the net
pay of the borrower indicated in the payroll is sufficient to cover the monthly amortization of this loan; and (4)
the information presented by the said applicant is true and correct.
Administrative Officer
Action taken:
( ) Approved
( ) Disapproved
( ) Others
(For Division Office Personal/EGT Applicants)
Schools Division Superintendent
or
Assistant Schools Division Superintendent
(For Regional Office Proper)
CHAIRMAN, Regional Secretariat
