AMDFormN01a

RevisedJuly2013

BANGKOSENTRALNGPILIPINAS

ASSETMANAGEMENTDEPARTMENT

PastePassportSize
IDPhoto
Here

TelephoneNos.3063422,30634233062914

ForTCTNo._________________
Location_________________

BUYERSINFORMATIONSHEET
(ForIndividuals)
(Pleasecompleterequiredinformation.IfnotapplicableputN/A.)

BUYERSPERSONALDATA
LastName:

FirstName:

MiddleName:

HomeTel.No.:
PermanentHomeAddress:(No.Street,Subdivision,Barangay,City/Municipality,Province)

HomeTel.No.:
PresentHomeAddress:(No.Street,Subdivision,Barangay,City/Municipality,Province)

DateofBirth:
PlaceofBirth:
Age:
Sex:
CivilStatus:

Male
SingleMarriedAnnulled

Female
Widow/er LegallySeparated
Nationality:
ACR/No.SIRV/SRRVNo.,ifapplicable

TIN:
FaxNo.:
CellphoneNo.:
EMailAddress:

GovernmentIssuedID
DateandPlaceIssued:
IssuedByandNo.:

HomeOwnership:
OwnedMortgaged
RentedatP_____________
LivingWithRelatives
No.ofDependent/s:

IFEMPLOYED

IFENGAGEDINBUSINESS

Company/Institution:

BusinessorTradeName:

CompanyAddress:

NatureofBusiness:

TelephoneNo.:

BusinessAddress:

GrossMonthlyIncome:

NetIncomefortheImmediatelyPrecedingYear:

OtherSourceofFamilyIncome
Source/NatureAmountperYear
______________________P______________
____________________________________

References
NameAddressContactNo.
______________________________________________
______________________________________________

SPOUSESPERSONALDATA
LastName:
Citizenship:

Age:

FirstName:

MiddleName:

TIN:

CellphoneNo.:

Company/Employer/BusinessName(ifselfemployed):

DateofBirth:

EmailAddress:

Company/Employer/BusinessAddress:

OfficeLandline:

EXISTINGLOANACCOUNTS/OUTSTANDINGCREDITS(Pleaseuseaseparatesheet,ifnecessary)
TypeofLoan:

Bank/FinancialInstitution/Creditor&Address:

OriginalAmount:

MonthlyPayment:

OTHERASSETS

EstimatedValue:

MaturityDate:

CREDITHISTORY

(Pleaseuseaseparatesheet,ifnecessary)
TypeofProperty/Investment:(e.g.house,car)

Location/Description:

OutstandingBalance:

Doyouhaveanexistingloanwithotherbanks,financialinstitutionsorgovernmentagenciessuchasPAGIBIG,GSISorSSS?
YesNoIfyes,pleasegivedetailsandsubmitproofoflastamortizationpayment
Aretherecases,pastorpending,civilorcriminal,filedagainstyouinvolvingnonpaymentofobligationsormishandlingorissuance
ofbouncingchecks?YesNoIfyes,pleasestatethenatureandstatusofthecase.____________________________

CERTIFICATION
I hereby certify that the above statements are true, correct and complete to the best of my knowledge and belief and hereby agree that any misrepresentation or
nondisclosureofamaterialfactshallbeagroundforthedisapprovalofmyoffer.IagreetonotifytheBSPofanychangeinmypersonalcircumstancesand/oranymaterialchange
inthedatastatedherein.IlikewiseauthorizetheBSPtoundertakewhateverinvestigationorverificationtocheckthevalidityorinformationcontainedherein.Lastly,Iunderstand
thatitmaybeacriminaloffensepunishablebyfineorimprisonment,orboth,toknowinglymakeuntruthfulstatementsorrelatedfalsehoodsuponanymaterialmatterconcerning
anyoftheabovestatementsunderthecriminallawsofthePhilippines.

_________________________________________________________
DateSignatureOverPrintedName

JURAT

RepublicofthePhilippines)
CityofManila)S.S.

SUBSCRIBEDANDSWORNTOBEFOREMETHIS______DAYOF_______,2011AT____________BY

________________________________________________________________
(NameofBuyer)Com.TaxCert.No.DateandPlaceofIssue

DocNo._____________
PageNo.____________
BookNo.____________
SeriesNo.___________

DOCUMENTARYREQUIREMENTS
Putamarkontheitemssubmitted:

()ProofofIncome(latestIncomeTaxReturn,Payslip,etc.)
()CertificateofEmployment
()DTICertificateofRegistration/BusinessPermit(photocopy)
()OnepassportsizeIDpicture
()GovernmentIssuedID&BIRTIN
()StatementofBankAccountorPhotocopyofPassbook
()BankCertificationonInvestment,ifany(photocopy)
()FornonresidentalienAffidavitonTotalLandholdings
()SpecialPowerofAttorney,ifrepresented