MEMBER'S DATAFORM (MDF)

FOR HDMF USE ONLY

Pag-IBIG MID No.

1210 9361 1740

Registration Tracking No.

121093611740

INSTRUCTIONS

1. The Member's Data Form (MDF) shall be accomplished in two(2) copies. 6.On the 'BENEFICIARIES' portion, the provision on the intestate

Succession, as Provided in the New Family Code shall be observed.

a. SINGLE - Mother, Father, Brother and/or Sister.b. MARRIED - Spouse,

Son, Daughter, Mother and Father

2. Type or print all entries in BLOCK or CAPITAL LETTERS.

3. The 'NAME EXTENSION' shal refer to JR., II, II and the like.

4. Indicate the full name of your FATHER and MOTHER as they appear in

you birth certificate.7. Submit MDF in two (2) copies and present at least one (1) valid primary ID.

5. Accomplish only the 'PERMANENT HOME ADDRESS' if it is different

with the 'PRESENT HOME ADDRESS'.8. For any subsequent change of information, please secure and accomplish

two (2) copies of the Member's Change of Information Form (MCIF)

[FPF110] and submit to the concerned HDFM Branch.

MEMBERSHIP CATEGORY

EMPLOYED PRIVATE SELF-EMPLOYED NOT YET EMPLOYED

EMPLOYED GOVERNMENT EMPLOYED PRIVATE HOUSEHOLD

OVERSEAS FILIPINO WORKER (OFW) INDIVIDUAL PAYOR

LAST NAME FIRST NAMENAME

EXTENSION(e.g. Jr., II)

MIDDLE NAMENO MIDDLE NAME

(check if applicable

only )

MEMBER LAGRAM A EDNA M AQUIPLANTA

FATHER LAGRAM A CRISPIN LACERNA

MOTHER (Maiden Name) M AQUIPLANTA ROSITA LUZ

SPOUSE (If Married)

MEMBERS'S NAME AS APPEARINGIN THE BIRTH CERTIFICATE LAGRAM A EDNA M AQUIPLANTA

DATE OF BIRTH

OCTOBER 10, 1989

MARITAL STATUS

SINGLE

TAXPAYERS IDENTIFICATION NO.

SSS NUMBER

GSIS NUMBER

EMPLOYEE NUMBER

For AFP/PNP Employee, Ser ial/Badge No.

For DECS Employee, Division Code-Station Code

-

PLACE OF BIRTH

MOGPOG, MARINDUQUE

CITIZENSHIP

FILIPINO

SEX

FEMALE

PROMINENT DISTINGUISHING FACIAL FEATURES

COMMON REFERENCE NUMBER (CRN) (If Available)

PRESENT HOME ADDRESS CONTACT DETAILS

Unit/Floor/Room No. Building(Indicate country code if abroad)

COUNTRY + AREA CODE TELEPHONE NUMBER

Home

Cell Phone

+63 0948 4826845

Business (Direct Line)

Business (Trunk Line)

Email Address

ednalagrama12@yahoo.com

Lot No. Block No. Phase No. House No. Street

Subdiv ision Barangay

INO

Municipality /City Prov ince/State(if abroad)

MOGPOG MARINDUQUE

Counry (if abroad) ZIP Code

PHILIPPINES 4901

PERMANENT HOME ADDRESS

Unit/Floor/Room No. Building Lot No. Block No. Phase No.

House No. Street Subdiv ision Barangay

INO

Municipality /City Prov ince Zip Code

MOGPOG MARINDUQUE 4901

PREFERRED MAILING ADDRESS Present Home Address Permanent Home Address Employer/Business Address

EMPLOYMENT/BUSINESS DETAILS

EMPLOYER/BUSINESS NAME

QUEZON-ROXAS HIGH SCHOOL OF MARINDUQUE FOUNDATION INC

EMPLOYMENT STATUS

Permanent/Regular Contractual

Casual Project-based

Part-time/TemporaryEMPLOYER/BUSINESS ADDRESS

Unit/Floor/Room No. Building DATE STARTED

JUNE 2013

Lot No. Block No. Phase No. House No. Street

CAMARINES STREETMONTHLY INCOME

Basic 6,000.00

Allowances/Others 0.00

Gross 6,000.00

Subdiv ision Barangay

DULONG BAYAN

Municipality /City Prov ince/State(if abroad)

MOGPOG MARINDUQUE

OCCUPATION

SECONDARY SCHOOL TEACHERS

Counry (if abroad) ZIP Code

PHILIPPINES 4901TYPE OF WORK (For OFWs only)

Land-based Sea-based

MANNING AGENCY (To be accomplished by the seafarers only) ASSIGNED COUNTRY (Land-based only)

PREVIOUS EMPLOYMENT FROM DATE OF Pag-IBIG FUND MEMBERSHIP

EMPLOYER/BUSINESS NAME

QUEZON-ROXAS HIGH SCHOOL OF MARINDUQUE FOUNDATION INC

FROM

JUNE 2013

TO

PRESENT

EMPLOYER/BUSINESS ADDRESS

EMPLOYER/BUSINESS NAME FROM TO

EMPLOYER/BUSINESS ADDRESS

HEIRS (In case of death, Fund benefits shall be divided among the member's legal heirs in accordance w ith the New Civil Code as amended by the New Family Code)

LAST NAME FIRST NAMENAME

EXTENSIONMIDDLE NAME

NO MIDDLE NAME(Check only if applicable)

RELATIONSHIP DATE OF BIRTH

LAGRAM A ROSITA M AQUIPLANTA M OTHER JUNE 15, 1954

LAGRAM A CRISTEL M AQUIPLANTA SISTER M ARCH 11, 1994

I HEREBY CERTIFY THAT THE INFORMATION GIVEN AND ALL STATEMENTS MADE HEREIN ARE TRUE AND CORRECT.

SIGNATURE OF MEMBER DATE

DISCLAIMER: Membership registration with the Fund does not automatically qualify a Pag-IBIG member to avail of the Fund's various loanprograms. A Pag-IBIG member must satisfy the eligibility requirements and comply with the documentary requirements, which issubject to verification and approval.