Republic of the Philippines

DEPARTMENT OF EDUCATION
Region V
DIVISION OF CAMARINES SUR
Freedom Sports Complex, San Jose, Pili, Camarines Sur

APPLICATION FOR GSIS LOAN

Type of Loan Applied:_________________________

NAME OF APPLICANT:

Last Name First Name Middle Name

Birth Date:_____________________________________________ Age:_____________________________________
Residential Address:__________________________________________________________________________
School Assignment:____________________________________________________________________________
Division/Station/Employee Number :_____________________________________________________________
UMID Card No. (The twelve digits number in your UMID card)____________________________________________
Have you Applied for GSIS loan previously?_____________________________________________________________
If yes type of loan applied:______________________ Date of Application:_______________________________________
Date of Original Appointment:_______________________________________________________________________
Status of Employment:_________________________ E-mail Address:______________________________________
Cell Phone Number:___________________________ Office/Home Phone Number:___________________________
I hereby certify under oath that:
(1) I am in the active service;
(2) I have no pending administrative case and/or criminal charge;
(3) The information supplied by the undersigned is true and correct;
(4) I am not on leave of absence without pay;
(5) That as of the month of __________ 2012, the following appears in my Pay Slip:
Gross Monthly Income: _________________________
Total Deductions: ______________________________
Net Take Home Pay: ____________________________
(6) The monthly amortization shall be deducted from my monthly salary;
(7) In case of separation from the service of the borrower, clearance shall first be
obtained from the GSIS before any document and/or final payment is released in
my favor.

(Signature over Printed Name of borrower)

Date Signed:__________________________________

Attested:

(Signature over Printed Name of the School Head)

Date Signed:__________________________________
Mobile Phone Number:_________________________