PSMBFI

PUBLIC SAFETY MUTUAL BENEFIT FUND, INC.

318 – 320 corner 1st and 2nd Streets, Brgy. West Crame, Bonnie Serrano Ave., San Juan City _____________________
Trunk Lines 8726-8070, 8727-3959,E-Mail [email protected] Extension Office/Branch

1997 LOAN APPLICATION FORM

(January 2020)
LOAN PARTICULARS
Loan Type:  PL  SL Plus  Emergency  Multi-Purpose  CL  Others_______ DATE: ✔
 New Loan PAYMENT TERMS
 Renewal  12 months  18 months  24 months  36 months  48 months  60 Months
AMOUNT (In Words): AMOUNT (In figures):

RELEASE OF LOAN PROCEEDS MODE OF PAYMENT: For Policy Loan Only (Pls. check one)

 Pick up  Mail to Region __________  Deposit to ______________  Automatic Salary Deduction

 Over-the-counter payment
This is to authorize Public Safety Mutual Benefit Fund, Inc. to credit proceeds of my loan to:  Deduction from loan proceeds
 Name of bank _____________________ Account number ________________________  Charged to Equity Value upon termination of membership
 Others: ________________________________________________________________
BORROWER’S DATA
RANK LAST NAME FIRST NAME MIDDLE NAME DATE OF BIRTH PAYSLIP ACCT NO.
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NAME OF AGENCY UNIT ASSIGNMENT/REGION ✔ CELLPHONE NO. TIN NO.
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DATE ENTERED SERVICE RETIREMENT DATE TELEPHONE NO. RIGHT THUMB

PERMANENT ADDRESS EMAIL ADDRESS

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HOME ADDRESS NAME OF SPOUSE

SIGNATURE OF BORROWER
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COMPLIANCE TO CREDIT INFORMATION SYSTEM ACT (RA9510)
In compliance, PSMBFI will submit your basic credit data as well as any regular updates or correction thereof to the Credit Information Corporation (CIC)
for consolidation and disclosure as may be authorized by CIC. Such credit data may be shared by CIC with other authorized lenders and other duly
accredited reporting agencies for the purpose of establishing your credit worthiness.
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___________________________________
Signature over Printed Name of Borrower
AUTHORIZATION TO DEDUCT (For PNP Only)
Please accomplish a separate Authority to Deduct for other agency
I hereby authorize PNP Finance Service (FS) to deduct from my salary/retirement benefits/commutation of leave credits/pension and pay the
sum of _________________________________________ (P_____________) every month for _____ months beginning _____________________ for
payment of my loan amortizations until full settlement thereof with PUBLIC SAFETY MUTUAL BENEFIT FUND, INC. (PSMBFI). I further authorize
PSMBFI to access my personal information under my Unit/Office electronic payroll system.
In case of dismissal, resignation, separation, voluntary or compulsory retirement or termination from the service for whatever cause, I, as the
borrower shall pay the outstanding remaining balance, including interest, costs, fines, fees, penalties, and other charges to PSMBFI from any and all pay
and benefits due me or legal heirs from my untimely death.
I hereby expressly waive all my rights under Section 13 Rule 39 of the Rules of Court, Republic Act Nos. 675 (PNP Law), 4917 (Retirement
Benefits of Employees of Private Firms), 9510 (Credit Information System), 10173 (Data Privacy), and to any and all statutory provisions relating to the
confidentiality of information.
I fully understand that the loan obligation is a contract between the PSMBFI and the undersigned borrower and thus, hereby assume all the
obligation that may arise thereof and hereby understand the PNP FS is not privy to the contract of loan executed with PSMBFI, but is merely authorized
pursuant to GAA to deduct loan obligation/s from the salaries of employees/retirees.
Thumbmarks

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_________________________________
Signature over Printed Name of Borrower

Subscribed and sworn to before me the ______ day ______________ at ______________________________, Philippines.

Doc. No. _____

Page No. _____
Book No. _____
Series of _____
DO NOT WRITE BELOW THIS LINE
PRINCIPAL ________________________ REMARKS:
OUTSTANDING BALANCE ________________________ _____________________________________________________________________
NET PROCEEDS ________________________ _____________________________________________________________________
MONTHLY AMORTIZATION ________________________ _____________________________________________________________________
LOAN NO. _____________ VOUCHER NO._____________ _____________________________________________________________________
EVALUATED BY: _____________________________________________________________________
REVIEWED/CHECKED BY _____________________________________________________________________
 PROMISORRY NOTE/LOAN AGREEMENT

KNOW ALL MEN BY THESE PRESENT:

In consideration of the loan received from PUBLIC SAFETY MUTUAL BENEFIT FUND, INC., I hereby
acknowledge the following:

1. Principal Amount : ______________

Loan Term : ______________
Monthly Amortization : ______________

2. As security of this loan, I hereby assign all rights and interest on my Equity Plan Certificate of
Membership as member of PSMBFI, up to the extent of loan balance.

3. All indebtedness under this loan shall become due and payable, and the Equity Value can be used to pay
off the indebtedness in case of:

a) Death of the member;

b) Retirement or discharge from the service/employment from the organization;
c) Voluntary termination of membership;
d) Dismissal with or without cause from service;
e) AWOL; and
f) Any reason, in which event the total amount of loan plus interest shall be deducted from any benefits
from PSMBFI.

4. If for any reason, the agency/organization to which I am receiving my salary is unable to deduct the
monthly amortization from my salary, I shall immediately remit/pay directly the monthly amortization to
PSMBFI Office. Otherwise, the unpaid installment shall earn interest at additional rate of _______% and
shall continue accruing interest until fully paid.

5. Pre-termination of loan shall be subject to a fee equivalent to five (5%) percent of the principal balance
plus any unpaid interest.

6. In case of separation from the service for whatever cause, the unpaid balance, including its accumulated
interest and surcharges as stipulated above, shall be deducted from my last payment, commutation of
leaves, pension and all other separation benefits and thereby waive my rights under applicable rules.

7. ESCALATION CLAUSE PENALTIES ATTORNEY’S FEES, COST & VENUE. In case of non-payment of
two (2) successive installments, the whole sum shall become immediately due and payable without need
of demand or notice, and I agree to pay by way of cash or deduction from my Equity Value as penalty
charges an additional amount equivalent to __________________ (______ %) percent per annum of the
total amount due, until fully paid and ______________________ (________%) of the total amount due as
attorney’s fees plus cost of suit and other litigation expenses. Proper courts in San Juan City, Philippines
shall be exclusive venue of any suit arising from this agreement.

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________________________________________
Signature over Printed Name of Borrower