Repubilic of the Philippines COMMISSION ON AUDIT PERSONNEL WELFARE AND ASSISTANCE ‘Commonwealth Avenue, Quezon City Tal. Nos, (02)86-8240 08451121279 Revised September 2019 OAN APPLICATION and PROMISSORY NOTE i ever aco ap fora oan wit LA. He ave read and undead te aes ond rsp of Grower and co-maer as ride i for a we re ware fhe BU oan ie offing our gnats lo maf or agroment whl te eting PLM pas, ran mtn LOAN AMOUNT: 8. BUY OUT LOAN: Onew met Hone vear (1 beposrr-LaP/PNB Acct No. Loan | El Educational _ | Ey two vears LOAN |] MAIL (Office Address) TYPE | [Dither TERM: | Fy ture years PROCEEDS [PF pickup Dormer LAST NAME FIRST NAME MIDDLE NAME EMPNO, _ POSITION, civiL status DATE OF BIRTH AGE OFFICE! HOME: i ava | ADDRESS : ADDRESS ae | (compete) (complet) | NET PAY. AS OF PHONE “Office Wabi | DATE OF ENTRYINCOA NOS. Home aE | Have you ever been formally charged eriminalyladministratvely?[_) Yes [_-] No Gwe details/status, if applicable | Fave you ever been uly of any adminatratve/orminal offense?T—] Yes [=I No Ghe detallsisatus, Fapplcable BORROWER'S UNDERTAKING [As Borrower, Icerfy that I have carefully read, clearly understood, and agree to the following: ly Ue required amortization; ry own payments, Pay directly to PWA in ease of inadequate deduction from slay {Assign al convey o the PWA any amounvbeneft due me from the COA or any other government agency to cover the setement of my loan, as may be necessary, 5. Authorize PWA to deduct from my dividend income, equity fund and any amount due from PWA in case of my failure to pay the monthly amorization, 6. Authorize PWA to deduct from the proceeds of my loan the delinquencies ofa principal borrower in whose loan Twas 3 eosmakers Authorize verification of my loa elighility with other COA Fis as tefleced on the application form prior t submission o PWA; 8. Find a replacement for my loa co-maker who goes on travel abroad, retires, dics, resigns or withdraws membership, otherwise, de existing €o miker shall not be cleared of accountability an! I shall not be allowed t avail of aby new or renewal of loan; and 9, Iivease of lavsuit arising rom this loan, Quezon City stall be the place of lawsuit and litigation, LAST NAME FIRST NAME, MIDDLE NAME, EMP NO, POSITION CIVIL STATUS DATE OF BIRTH OFFICEY HOME ADDRESS: ADDRESS scene (complete) a (complete) NET PAY, __AS OF PHONE ~ Office DATE OF ENTRY IN CO NOS. Home LAST NAME FIRST NAME, MIDDLE NAME EMP NO, POSITION IVIL STATUS DATE OF BIRTH AGE _ | OFFICE HOME wanna | ADDRESS ADDRESS a (complete) ee (complete) | NET Pay. AS OF PHONE "Office DATE OF ENTRY IN COA, NOS. Home 2, infra yale uaa Form ras, at ay nae te her Ate, Fe fe Chama bath oeLAST NAME FIRST NAME MIDDLE NAME EMP NO. POSITION, CIVIL STATUS DATE OF BIRTH AGE OFFICE HOME Goad ADDRESS ADDRESS | (complete) (complete) NET PAY. ‘AS OF PHONE ~ Office Mobile DATE OF ENTRY IN COA NOS. Home Leave Credits (Wiest) ‘CO-MAKERS UNDERTAKING ‘As the above-named Co-Makers, we ceri tht we have carefly read, clery undertood and agree tothe lowing: 1. We shall be joinly and slidarily liable with the principal borrower, 2 We authorize PWA, through the Finance Ofice (Central oF Regions), to deduct from our monthly salary the required monthly amortization unt dhe loan of de principal borrower is fully paid, assign and convey to PWA any amouni/bencfit due vs fiom COA or any ober government agency to cover the seitlement ofthe borrower's loan of which we are co-makers; and We commit to find a co-maker replacement in ease any one of us goes on uavel abroad, redres, resis, or wildraws our membership. We ean only be eleared after the approval by die PWA of the quaiied co-maker replacement. 4. Incase of lit arising from this loan, Quezon City shal be the place of lawsuit and litigation, Signe ver Name of Coan Spans ver Name of Co "Biptar oer Name of CMake ery fad Date Sige ca usd Date Spied ad Date Sand Regional Accountants Cericaion ‘Regional Office No. BORROWER'S NET PAY! for the MONTH/YEAR + No window dressing has been done on the borrower's net pay. all deductions requited have been effected from the salary: the Ioan amantzation ‘payment for ths loan shall be deducted 2s biled by PWA: and no deletion or change of payment shal Be dane unless the loan fly pai, oF & ‘ew billng s made, ora notice fom the PWA I recelved: ana + Lamaware of my responsibiles as provided for under COA Memo 96-015 dated April 25, 1996, Signature Printed Name/Position Date signed ivanciaLinsrumion | \Loantyee Actual Payment Vere by sis HOMF PIIGASEA ecu CREMG [staca [ RO Coop/Assn FOR PWA USE PWA Existing Loan as of, Date Monthiy Amount Granted Te ‘mors ‘Balance Adaliional Notes RL eeevae nsee pee atest neee vereseesTeereate feet eecareecee ema eave ow dad seceevea rerecemeaes earee ere meee roe ‘Slats of Borower ana Comarers Mlamborigoos.sanaing Borrower Oye EN Co-makert Dves = no Comaker 2 Yes No Comaker 3 Yes No -PROVED/DISAPPROVED: rocessar TOate RaviewerDate “Roproving Offeer Dae