Bureau of Jail Management and Penology Mutual Benefit Association, Incorporated 144 Mindanao Asean, Babsy Taro, Quezon City, Metro Mails "TeLiFax: 02-926-6963 ~ 02-54-6671 » 0939-920-2510 -0917-531-7092 Email Addbess bjmpaabai@yaboo.com ph APPLICATION FOR LOAN Application No. For Pick-up Date Received > For Mailing CLICNe. > For Deposit TYPE OFLOAN: REGULAR [EMERGENCY Ccaranary BANK ACCOUNT NO. BRANCH CEDUCATIONAL QEQUITY C]MEDICAL [JHOUSING [] VEHICLE STATUS: [New Loam Renewal TERM(months):06 O12 O18 O24 036 O48 O60 (Others Siv/Madam: The undersigned, 2 member of BIMPMBAI, hereby request for 2 Salary Loan in the amount of) tinder the terms and conditions stipulated in the Promistory Note at the back hereof, ‘The following document: are submitted for your evaluation, namely: 1. Latest payskip with Net Take Home Pay (NTHP) of at least P and 2. BYMPMBAU/BIMP Identification Card (Nerox Front and Back of ID). PURPOSE OF LOAN: is. Check) () Livelihood (© Health / Medical Needs () House Improvement () Education () Augmented Family Income () Othess: gNAME (Last, First, Middle) ‘DATE OF BIRTH (mm/dd/yy) RANK DESIGNATION PRESENT UNIT ASSIGNMENT & ADDRESS. _, RESIDENTIAL PROVINCIAL ADDRESS: (dicate house mmaber, street, cityiasuicipality) _ HOBILETANDLINE CONTACTO. ‘NAME OF SPOUSE/BENEFICIARY AND ADDRESS: (RANK NAME AND SIGNATURE OF BORROWER) (TO BE FILLED UP BY AUTHORIZED BJMPMBAI PERSONNEL) STATUS OF EXISTING LOAN (DateGranted) (Original Amount) (Maturity Date) (Present Balance) (Remarks) BORROWING CAPACITY (Loan Amount is computed based on one’s capacity to pay or Net Take Home Pay(NTHP) ‘Other Loans: MAXIMUM AMOUNT P — P—__—_ ‘Recommended Loan Amount PB P Payablein Months to begin on P and eadon P ‘Monthly AmortizatiowPayment — P —__—_ rp NEP after deducting MA P REMARKS. REMARKS: Procezzed By: TLom Processor Cl approven C1 psareroven RECOMMENDED APPROVAL FOR THE BOARD OF DIRECTORS (GENERAL MANAGER) (PRESIDENT)PROMISSORY NOTE LOAN AMOUNT P 20 FOR VALUE RECEIVED, I PROMISED TO PAY TO THE DEMAND OF THE BUREAU OF JAIL ‘MANAGEMENT AND FENOLOGY MUTUAL BENEFIT ASSOCIATION, INCORPORATED (BIMPMBAD) AT ITS OFFICE IN METRO MANILA, PHILIPPINES, THE SUM OF e ) FHILIPPINE CURRENCY WITH INTEREST OF FERCENT(__| Incase I fail to pay the principal amount of this Note at maturity or on demand, 2s the ease maybe, then the entire principal shall, at the option of the Association and without necessity of notice to me, immediately become due and payable; and I agree to pay the interest at the rate of percent (%) plus 2% surcharge per month on the amount due compounded monthly until obligation i fully paid: Tn case of non-payment and this note is refered to a lawyer for collection, I agree to pay a reasonable amount for attomey’s fee: and in the case of judicial suit for collection, to pay the Acrociation all the outstanding amount, in addition to the cost of the suit and/or other incidental expenses; T hereby authorize and empower the Association at it's options at any time, without notice to pay, apply to the Payment of this loan any or all moneys, securities and things of value which may hereafter be in its hands or daposits or ofherwise to the eredit of or belonging to me, and the Aczociation ie hereby authorized to call at public or private sale such securities, or thing: of value for the parpoze of applying the proceeds thereof fo such payments; [further agree in case of separation from the service /employment of whatever causes, that the unpaid balance, with its accumulated interest and such surcharges stipulated above, be deducted from my last payment, commutation of leave, refund: and/ or from my pensions; ‘fafier one (1) month no deduetion has been effected om my payslip, i will eallinform BJMPMBAL office. I will personally pay the amortization/s not deducted from my payslip. In any ease, however, surcharge for non-payment will be imposed. Finally, I hereby authorize and empower BJMPMBAI to assign to any financial institutions this PN without the need of prior notice to the undersigned principal borrower. Signature over Printed Name of Borrower AUTHORIZATION FOR PAYROLL/PENSION DEDUCTION AND REMITTANCE, TO WHOM IT MAY CONCERN: ‘There by authorized the deduction from my payroll/pension and remittance of the amount of Pesos (P, ) every month beginning, 20___ for payment of my obligation with BIMPMB AI until same obligation will be fully paid. This authorization shall not be rescinded. ‘without the conformity in writing of the BIMPMBAL If the amount is not deducted and) or remitted by my Finance (Officer, I oblige to accelerate my payments to pay it personnaly and to-update my accounts while the obligation is still subsisting. IN CASE I AM SEPARATED FROM MY PRESENT EMPLOYMENT BEFORE THE FULL PAYMENT OF MY LOAN, I SHALL PAY THE BALANCE, INTEREST, FEES AND COSTS TO THE BJMPMBAL I AUTHORIZE MY FINANCE OFFICER TO DEDUCT FROM MY PENSION/ALLOWANCE/BENEFITS. AND I WAIVE MY RIGHTS UNDER RA 2310 AND RULE 39, NEW RULES OF COURT AS AMENDED. IF MY RETIREMENT PAY COMES FROM THE COVERNMENT OR PRIVATE OFFICE, I LIKEWISE AUTHORIZED MY FINANCE OFFICER TO DEDUCT AND REMIT THE ACCOUNTS OUTSTANDING TO. ‘THE BJMPMBAL ‘Signature over Printed Name of Bonower CERTIFICATIONS hereby certify thatthe applicant is Thereby certify that Therby undertake to deduct the amount indicated ‘not due for separation during the the applicants har {in the above zuthorization and remit the same to ‘terms of his/her loan the Association. I shall inform the Association Dino pending ease ‘of any change in pay status of the borower and 7 shall issue no clearance until the obligation is Cipending case fully paid and with written conformity of the ‘Association Personnel Officer Legal Officer Finance Officer Signature Over Printed Name Signature Over Painted Name Signature Over Printed Nameolieyholder Berne tical oc emesocyunraseen: Se ——| LIFE INSURANCE 10632) 01-867 (+652 810-220) or 95, 652) 88-2802 COMPANY, INC. enue teintss) Cease eerie aie uueienskont et Benin bo Noe of Borowe as Fa a) Civ [Fee Residence Address (no. street, municipality) 7 Pres vanaiy ai Date of Birth [et ne. [ occpatonSpecie Jb [ Source of income Employer's Name & Address Boum Relationship PL Birthday | Age [ Trust i ony beneficiary is under 18 years of age: Rolatonship of Trustee to tAnor Bonofcary: a Inthe event ofa claim, Beneficial Life Insurance Company in. shall pay to the Policyholder the proceeds under the Policy which shallnot exceed the loan balance atthe time ofthe death ofthe insured Debtor. The excess from the proceeds, any, shal be pald tothe designated beneflclany/ies, and in the absence ofthe latter, shall be paldin accordance withthe group policy contract. [2 [cecieration ac Representations | hereby warrant and declaro, to the best of my knowledge, that on the date of release of my loan, | am in good health and physically able to perform the usual activities In the pursult of my livelihood, and that: 1. Within the last two <2) years. Ihave not ade ary sppleation for Insurance which has been declined, postponed, withdrawn oF accepted on a basis ‘other thar applied Fer, EXCEPT 2. Lhave not had any symptoms oF sought advice Ter, of have been Weated for high blood pressure, stoke, haan Wouble Glabeles cancer oF lmnour hast pain, bleeding from the bowel, or bicod In your sputum, or has Weatment for any ofthese constione been recommended by 8 physilan oF '. Within the last five (5) yoars, Ihave not been adnited or been advised > 4.1 dort have any health sympioms or complains for whlch a physidan hasbeen consulted or Weatment as bean received, La. peraistnt fever, unexplained weightloss, loss of appetite, pain or swelling, ete, EXCEPT 5. Please enumerate any cesaze of consultation being done it any aes 6. Are you pregnant? If 0, how many months? ctemale applicant eri) Bom By signing this form and continuing to aval of BenLife's products and services, | hereby: 1 Conty thet the sbove statements sre true and complete and that all exceptions have been stated. 1 have not withheld any relevant Information which might have otherwise affected the acceptance of my proposal. | und net the Insurance applied for will become effective only upon acceptance by Dentife and the intial premium being fully pald by me. Any materiel {atsty or misropresentation In the foregoing, upon dlacovery thereot within one (I) year fom the effectivity date of the Insurance Dolly shall entitle BenLife to declare such polcynulland vokd fromthe beginning. ty Authorize any physician, hospital, linc, Insurance company or other organization, institution or person, that has any of my health fecord, to gWve Dentife or its legal representalve, any end such ell information; ond agree that © photocopy of this Authorization ‘hallo effective andvelld as riginal. 9 Agree that these Information (personal and sensitive) can be proce 1d, shared, disclosed, transferred or used by Bentite ‘sdvisore, representatives, external audtors, and ‘a5 may be amended from time to time to, and Including its shareholders, directore and employeos, Ite affiliates and subs wee ary service providers witnin the rules set by the Data Privacy Act of Fegulations, to commulnieate with me on Denuif's products and services; conduct data analytics, prfiling and automate rocassing; comply with regulatory requirements, legal and contractual obligations of Bentife: and for other reasonable purposes related to the services providedar improvement/upgrede nsystems end business processes. DiscLosurE: Im accordance withthe insurance Commission's Cheular Letter No. 2016-54, your medical information wil be uploaded to a Madieal Information Database accessioe tle insurance companies forte purpose of ennencing rk esuesament and preventing fraud. Once uploaded, all fe insurance ‘companies will only have limited access to you rformation inorder to protect your nghtto privacy In accordance with aw. Acopy of Circle Letter No. 2016: 54!may be accessedat the folowing ink ww MSuAnCR.GOE, Ped one “Tos [our Stu Date Signed [Name of witness [Place of Signing [Witness Signature For Benlife Use OnlyBureau of Jail Management and Penology Mutual Benefit Association, Incorporated 14 ninco Avenve aha Tero, vero Cy, Metro Marka Tk: 02926 449 REPUBLIC OF THE PHILIPPINES. (QUEZON CITY ) 5s. PROMISSORY NOTE AND AUTHORITY TO DEDUCT of legal age, single/ married, with residence and postal address ater being swom to in accordance with law. depose ot and say: 1. That forvalve received, | promised to pay on maturity and cron demandto the Bureau of JallManagementand Penology Mutual Benefit Association, Inc. (BJMPMBAl) at its oie the sum of pesos, P J with interest of = _ percent {___%) per annum: 2. That for purposes of paying my loan obligation, | authorize the BIMP Fnance Officer or his duly authorized tepreseitative to deduct from my monthly payrol/pension the monthly loan amortization as scheduled unt it is fuly pia: 3. That as a member on account of this loan | also unconatiionally assigns the proceeds of my fe insurance to {guarantee full payment of my loan. Thus. if! die, | authorize BIMPMBAI to cutomatically deduct ail or part of my insurance proceads for the satisfaction of my unpaid loan 4 That in case the amorlzation was not deducted and or remitted by the Finance Officer or his duly authorized representative to BIMP MBAI, | oblge myself fo pay it personally and if | failed fo pay, then the entire principal shall become due and demondabie with interest of §% fo 12% per annum depending on the type of loan ‘availed of plus 2% surcharge both compounded monthiy until the obligation is fully settled. Further. notice is not necessary ‘5.Ihat in case of my separation from employment for any cause. | authorize the Finance Officer or his duly epresentative to deduct the entire outstanding loan balance from my leave credits pay. gratuity pay and other benefis that may be granted or in case of my retirement, the entire outstanding loan bolance be deducted from my leave benefif, gratuity benefits, pension and or other benefits alowed by law and remit the same to the BIMPMBA\ 4. That if transferred to other government agency, | authorize the Finance Otficer or the duly authorized representative where | was transferred to deduct the monthly loan amortization from my monthly payroll pay untiful payment or fo deduct the entire amount of my loan balance from my leave credits pay or gratuity poy in case of separation or retement. f employed in a private company, | authorize the payroliinance officer of said company to deduct the monthly loan amortization trom my monthly salary unt full payment or in case of ‘separation oF retirement, to deduct the entire outstanding loan balance from separation pay, retirement pay ‘and other sources of benelifs ike in CBA, etc, ond remit the same fo BJMPMBAL 7.That in case my account was referred 1o a lawyer or o a collecting agency to enforce payment, | agree to Pay the Atfomey's fees/collecting agency ees/charges and iin @ judiciol suit to pay the Attomey's fee. the entire amount of my account plus 25% charge in case of judgement in adaition to the Cost of the suit and other incidental expenses: 8, That finally, Lacknowledged that this Promissory Note and Authority to Deduct is part and parcel of the loan ‘@ppilication | signed and filed with the BJMPMBAI and the provisions of the loan application including terms and Cconaitions ofthis Promissory Note and Authority to Deduct shall be applied to govern the rules between the me ‘and the Association. IN WITNESS WHEREOF, | have hereunto set my hand this day of 20__, in Quezon City, Philippines. (Affiant) SUBSCRIBED and sworn fo before me, this__ day of. in Quezon City. Philippines, with the cffiant exhibiting his/her Community Tax Certificate No. issued on at NOTARY PUBLIC DoeNo, ‘Commission Serial No. Page No, 4 Until December 31, Book No. : Roll of Attomey Series of 1BP No. / Date/Place of issue PIR No. /Date/Place of IssueCOVID-19 QUESTIONNAIRE (To be completed by the Applicant) ‘COMPLETE NAME OF APPLICANT: a DATE OF BIRTH: — SSeS ERE S ED nna EERE OCCUPATION: NATURE OF BUSINESS OF EMPLOYER: 1. Have you been in close contact with or exposed to any of the following: a. Aperson confirmed tohave COVID-19? Oves Ono b. Aperson suspected tohave COVID-19? Oves Ono © Aperson under quarantine or self-isolation? Yes ONO d. Apperson providing direct care to a confirmed COVID-19 patient? Oves Ono .Aperson providing direct care to a person suspected tohave COVID-19? « ClYes. © ONO. f. Aclassmate, or officemate or any colleague, or occupant in the same building, or neighbor or ‘anybody in your barangay, who is suspected tohave COVID-19? Oves Ono 2. In the past 14 days, do you have fever and/or cough, muscle ache, loss of smell or taste, diarrhea, shortness of breath or other respiratory symptoms? Ol YES Ono 3. Have you been tested for COVID-19? Oyves Ono IFYES, please answer the following: a. When were you tested b. What was/were the result/s (rRT-PCR and/or ROT)? © What was the disposition (self-isolation or hospital confinement)? 4. Have you been diagnosed as a confirmed case of COVID-19? Oves Ono If yes, please provide the following: a. Exact date & time you were diagnosed Name of attending physician/s: Name of hospital/clinic: b. Were you confined in a hospital? OI YES ONO. yes, Date admitted: Date Discharged: Length of stay in the hospital Were there any complications? Oves Ono ITYES, please specify details of the complications. d. Was the COVID testing repeated before you were discharged from the hospital? Oves No Please provide date/s tested Results (rRT-PCR and/or RDT) 5. Have you visited a physician or any physician in a clinic or hospital, or a doctor’s clinic in a hospital, or visited the emergency room or urgent care room of a hospital for consultation and treatment in the ast 30 days? Oves Ono IFYES, please specify the exact date of consultation, physical complaints or reason/s for consultation, ‘exact diagnosis, name of clinic/hospital and attending doctor's specialization.6. Have you accompanied a patient or visited 2 COVID -19 patient or a person suspected to have COVID- 19 oF any patient inflicted with other illnesses, in the emergency room or urgent care room of a hospital or any hospital or clinic in the past 30-days? Oves ONO IFYES, please specify the following: Exact date/s of visit/s ee eee eee Patients inessfet ee Dectar'sspectakestion 11 LEI EEE SEL or eee ee eee Name of hospital 7. Have you or any of your household member travelled to or from another country or travelled in an ‘area within the country with confirmed cases of COVID-19 in the past 30days? Dyes ONo 8. Doyou presently reside in a country, or a city, or a barangay, with confirmed cases of COVID-19? Oves no IFYES please specify the exactlocation 9. Doyou have any history of hypertension, diabetes mellitus, cardiovascular diseases, or kidney diseases or lung diseases, or cancer, or stroke, or thyroid diseases or underwent transplant of any major organs or currently taking immunosuppressive drugs/medication? () YES LINO It yes, please specify the illness and the medication being taken 10, Have you ever smoked cigarette or tobacco or sought advice or treatment for excessive use? Oves Ono If yes, how much do you consume in a day? lO sticks/day 11-29 sticks/day 920 sticks/day LL. Are you pregnant? ves Ono If yes, please provide the Date of your last menstruation or expected date of child delivery 12, Do you have any medical complication due to pregnancy (e.g. gestational diabetes) or have you experienced any unusual bleeding or abnormalities in menstruation, pregnancy or childbirth? Oyes Ono IFYES, please provide details DECLARATION | declare that the above answers are true to the best of my knowledge and that | have not withheld any information that may influence the assessment or acceptance of my application for insurance cover. | agree that this supplementary statement will form part of my proposal to the company and that non-disclosure of any material fact known to me may invalidate the contract. Signature of the Applicant: eee Date Signed: