Annex B-1

LAND BANK OF THE PHILIPPINES

LIVELIHOOD LOAN APPLICATION/AGREEMENT FORM Revised 4/2013
(Please read Terms and Conditions at the back before filling up this form)
TO BE FILLED UP BY APPLICANT/BORROWER
Type of Loan: New Renewal
Type of Applicant: Private Employee Government (GLGC) Employee Government (LGU) Employee Barangay Official
APPLICANT (First Name, M.I., Surname) PN Number

Residence Address Zip Code Tel. No.

Provincial Address Tel. No.

Birthdate Age Gender Civil Status Department

Male Female Single Married Widow/er
Type Position Employee No. Years In Service End of Term (for Elected only)
Rank & File Officer
Elected
SSS/GSIS No. TIN Basic Pay Net Pay CA/SA No.

TO BE FILLED UP BY CO-MAKER
CO-MAKER (PLS. PRINT: First Name, M.I., Surname)

Residence Address Zip Code Tel. No.

Birthdate Age Gender Civil Status Department

Male Female Single Married Widow/er
Type Position Employee No. Years In Service End of Term (for Elected only)
Rank & File Officer
Elected
SSS/GSIS No. TIN Basic Pay Net Pay CA/SA No.

APPLICATION/AGREEMENT/PROMISSORY NOTES
I/We hereby apply for a Livelihood Loan in the amount of PESOS ____________________________________________________ (P ____________) .
We hereby swear that: (1) we are up-to-date in the payment of our existing loan; (2) we have no pending application for retirement or are not due for
retirement within the next ______ years from execution hereof; (3) we are regular/permanent employees of the _______________________________________;
(4) we are not respondents/parties of any pending administrative or criminal cases; (5) I, the co-maker, is not a co-maker of another borrower-employee with
outstanding livelihood loan under this facility; and (6) the statements declared above are true and correct to the best of our knowledge and that the application
is made for the purpose and consideration expressed above. We agree that should there be any misrepresentation discovered, the Land Bank of the Philippines
may cause the outright disapproval of the loan application and if the loan has already been granted, LANDBANK may immediately declare the loan due and
demandable.

We jointly and severally promise to pay to LANDBANK the amount applied for in accordance with the terms and conditions printed at the back thereof,
which we acknowledge to have read and clearly understood.

We hereby authorize:
the Accounting Department or Collecting Officer/Treasurer of our Employer/Government Unit to deduct the monthly installment on this loan from
our salary or from any form of benefits due us for payment/application to the monthly amortization on this Loan, until the loan and all interest and
fees related thereon are fully paid.
LANDBANK to debit our ATM Payroll account No. _________________for payment/application to the monthly amortization on this loan, until the
loan and all interest and fees related thereon are fully paid.

Signature Over Printed Name of Co-Maker Signature Over Printed Name of Applicant/Borrower
(To be filled up by Employer)
EMPLOYER CERTIFICATION
Office : Date :
This Office certifies that:
(1) the above information and signatures of applicant/borrower and co-maker are authentic;
(2) the above applicant and co-maker ;
are permanent/appointed employees of this Office and have been in the service for at least one year except elected officials and
are not on leave of absence without pay;
have no pending administrative and/or criminal charges against them;
have no pending application for retirement or are not due for retirement within the term of the loan
are up-to-date to the payment of their existing loans, if any ;
are presently receiving a net take home pay of not less than P_______ after statutory deductions and net of all loan of all amortizations
including the livelihood loan approlied for (except for Barangay Officials)
(3) the co-maker is employed in this Office with a rank at least equal to that of the borrower and is not a co-maker of another employee-borrower
with an outstanding livelihood loan under this program.
This Office certifies that the net take home pay of the applicant/borrower as of _______________ amounted to PESOS __________________________
_________________________________ (P_____________).
This Office agrees to collect the monthly installment/amortizations due on the loan of the borrower:
through automatic salary deduction by LANDBANK via DMVAL Facility ; or
through automatic salary deduction and remit immediately to LANDBANK not later than five (5) banking days after payroll date.

Name in Print Designation Signature of Authorized Signatory

TO BE FILLED UP BY LANDBANK
EXISTING LOAN: Borrower EXISTING LOAN: Agency/Entity as of DOCUMENT CHECKLIST
Date Granted : Total Outstanding Balance P ( ) Photocopy of Company/Office ID
Amount Granted : Current P ( ) Photocopy of Payslips
Outstanding Balance : Technical Past Due/Rate P % Certificates of:
Arrearages : Actual Past due/Rate P % ( ) MNTHP ( ) Honorarium
Combined Past Due/Rate P % ( ) Nature of Appointment
( ) Others ____________

Processed by: Reviewed by: Approved by;