KASANYANGAN CENTER FOR COMMUNITY DEV’T. AND MICROFINANCE FOUNDATION, INC.

(KCCDMFI)
KCCDFI Building, MCLL Highway, Guiwan
Zamboanga City
Tel. No. 062 991 93 48

LOAN APPLICATION FORM (recent picture here)

Date of Application : ______________________________

Branch Name : ______________________________
Center Name : ______________________________ A/PN: __New; __Repeat
DATA PRIVACY CONSENT

In compliance with the requirements of the Data Privacy Act of 2012, I hereby agree and authorize Kasanyangan Center for Community Development and Microfinance Foundation, Inc.
(KCCDMFI) on the general use and sharing of information obtained from me in the course of my membership. These data, which include my personal and sensitive personal information, may
be collected, processed, stored, updated, or disclosed by the KCCDMFI (i) for legitimate purposes, (ii) to implement transactions which I have requested, allowed, or authorized, (iii) to offer and
provide new or related services of the KCCDMFI or other related government agencies, and, (iv) to comply with the KCCDMFI internal policies and its reporting obligations to governmental
authorities under applicable laws.

______________________________________ _______________________________
Signature over printed name Date and Place signed
I. BORROWER INFORMATION (IMPORMASYON UKOL SA APLIKANTE)
Name of Borrower: (Last Name) (First Name) (Middle Name) Home Address: (No. & Street, Barangay, City/Municipality, Province)

Mobile Phone Number:

II. LOAN INFORMATION (IMPORMASYON UKOL SA LOAN)
Loan Purpose: Loan Amount Applied:
Latest six (6) cycles loan acquired from KCCDMFI Loan Type:
Amount Cycle Amount Cycle  RPA 6 NB  RPA 3 mo.  EDUC  iCARE
1. 4.  RPA 6 RB  RPA 4 mo.  HRL  Corn  Rice
 RPA – 100k+  RPA Balik  ACWA12  Vegetables  Hogs (fattening)
2. 5.  RPA – Sr. Centro  ACWA12 – S  Seaweeds  Crabs (fattening)
3. 6. Loan Amount Approved: Date: Cycle:
Approved by: Date Amount Signature
Field Credit Officer:
Branch Manager:
Area Manager:
Field Operations Head:
COO / President:
III. PROMISSORY NOTE (PANANAGUTAN SA PAGKAKAUTANG)
I, Mr./Mrs./Ms. ________________________________________________, We as co-borrowers, hereby states that we fully understand the significance of this
promissory note and agrees to the liability/responsibility of paying the due amount in case the
of legal age, married to ___________________________________________________ borrower cannot pay its obligation to KCCDMFI.
with residence at ________________________________________________________ CO – BORROWERS:
hereby agrees that this statement is a confirmation that I/we have an outstanding loan 1. _______________________________________________ ____________________
Printed Name of Family Co – Borrower Signature
with KCCDMFI as follows:
1. Loan Amount : ₱____________________ 2. ________________________________________________ ____________________
2. Interest Rate in ______ months ________ % Printed Name of Family Co – Borrower Signature
Corresponding Amount : ₱___________________ 3. _______________________________________________ ____________________
3. Duration of payment: ____ months or _____weeks Printed Name of Neighbor/Friend Co – Borrower Signature
TOTAL DUE : ₱____________________
4. _______________________________________________ ____________________
4. Loan Amortization : ₱ ________________ per week Printed Name of Center/Friend Co – Borrower Signature
CBU : ₱ ________________ per week
MBA : ₱ ________________ per week Witnessed by:

TOTAL WEEKLY AMORTIZATION : ₱ ________________________ ________________________________________________ ____________________

Printed Name of Center Chief / Center Official Signature

I promise to pay my weekly loan amortization including the CBU & MBA religiously and on time which will start on ________________________________ until the whole sum of principal and interest will be
fully paid on _______________________. As long as the interest is not fully paid, ownership – right of the assets acquired by the loan will belong to KCCDMFI. I will not transfer these assets to anybody under any
circumstances. Furthermore, should there be default in the payment, or diversion of the loan proceeds, the whole unpaid balance shall become due and demandable.

I promise to obey all rules and regulations in connection with the loan provided to me by KCCDMFI. I also promise to fully pay the loan even in the event of losses or damages of assets acquired from the
proceeds of the loan.

In case of default or overdue loan payments, I will voluntarily allow KCCDMFI to conduct “follow – up” in our house, pull – out property inside our house as my loan payment or sue me in the regular court
for non – payment of the loan. I further promise to pay any expenses incurred during the follow – up. No objection will be raised in this regard by my successors or me, and even if such objection is raised, will have no
validity in court. I/We, with my/our knowledge and freewill sign/s this promissory note.

____________________________________________ ____________________________________________
Signature of Borrower Signature of Husband
V. WAIVER (PAGPAPAUBAYA)
I hereby certify that all the information given are true and correct as to the best of my knowledge. That, I authorize you to verify and investigate it from whatever sources you may consider appropriate.
This authorization also allows said sources to furnish you information concerning my deposit accounts, placements or credit dealings and any other information that may be requested.

I understand that falsifying any information on the enclosed documents is sufficient ground for legal action and for rejection of my application. I understand that should my application be declined, KCCDMFI
has no obligation to furnish the reason for such rejection.

I hereby acknowledge and authorize the following: (1) the regular submission and disclosure of my basic credit data (as defined under RA No. 9510, or the Credit Information System Act, and its
Implementing Rules and Regulations) to the Credit Information Corporation (CIC), as well as any updates or corrections thereof; and (2) the sharing of my basic credit data with other lenders, as authorized by the CIC
and other credit reporting agencies duly accredited by the CIC; and for the sole purpose of establishing my credit worthiness.

__________________________________ __________________________
Borrower’s Signature over Printed Name Date

KCCDMFI Loan Application Form – Revised August 1, 2020

 C A SH FLO W A N A LY SIS, CH A R AC TER A SSESSMEN T & PO V ER TY PR O B A B ILITY IN D EX

CASH IN – FLOWS ATTITUDE ASSESSMENT SCORE

Sources of Income Occupation Daily Weekly Monthly 1. Loyalty to KCCDMFI (0-3)
Income from Sales 2. Honesty (0-2)
Business 1 3. Behavior in the Center Meeting (0-1)
4. Respect and Courtesy (0-1)
Business 2
5. Interpersonal Relationship with co-members(0-1)
Business 3 6. Charitable/helpfulness/Generosity (0-1)
Total Business Income 7. Cooperation/ Sense of Volunteerism (0-1)
Household Income TOTAL SCORE
Salaries & Wages ATTITUDE RATE (total score÷10 x 100%)
Member
Husband LOAN APPROVAL COMPUTATION
Children
Repayment Rate (R) :______________ X 60% = ________
Pension Attitude Rate (A) :______________ X 40% = ________
Remittance Abroad Overall Performance Rate (R+A) = ________
Rental
Other income sources Approved Loan Amount
Total Household Income (Overall Performance Rate X loan Applied)

(A) TOTAL INCOME

CASH OUT – FLOWS 2015 Philippines PPI Scorecard for the National Poverty Line
Expenses Daily Weekly Monthly Points
Business Expenses Indicators Responses (National
Raw Materials/Purchases Poverty
Line)
Business 1 1. In which region does the family live? A. ARMM 0
Business 2 B. Ilocos 8
Business 3 C. Cagayan Valley 8
D. Central Luzon 6
Salaries & Wages E. Calabarzon 9
Rent F. Mimaropa 8
G. Western Mindanao 5
Water H. Bicol 4
Electricity I. Western Visayas 8
Fuel J. Central Visayas 4
K. Eastern Visayas 2
Transportation Expenses L. Northern Mindanao 0
Business Taxes & Licenses M. Southern Mindanao 6
N. Central Mindanao 2
Other Business Expenses O. NCR 12
(B) TOTAL BUSINESS EXPENSES P. CAR 7
Q. Caraga 0
Household Expenses 2. How many members are there in the A. 7 or more 0
Food family? (exclude members who are B. 5 or 6 9
overseas Filipinos)* C. 4 and below 18
Clothing
3. What is the highest grade completed by A. 6th grade of school or lower 0
House Rental/ Amortization the head of the family? B. Some high school 6
Transportation C. Completed high school 7
4. What type of construction materials are A. Light materials (cogon, nipa, anahaw), 0
Fuel the roofs made of? Salvaged/makeshift materials, Mixed but
Medical Expenses predominantly light materials, Mixed but
Charcoal/wood predominantly salvaged materials

Kerosene B. Mixed but predominantly strong materials 5

LPG
C. Strong materials (galvanized iron, 6
Communication aluminum, tile, concrete, brick, stone,
Water asbestos)
Electricity 5. What type of construction materials are A. Light materials (bamboo, sawali, cogon, 0
the outer walls made of? nipa, anahaw), Salvaged/makeshift
Other Household Expenses materials, Mixed but predominantly light
Education materials, Mixed but predominantly
salvaged materials
Tuition
Allowance B. Mixed but predominantly strong materials 7
Transportation C. Strong materials (galvanized iron, 8
Other Education Expenses aluminum, tile, concrete, brick, stone, wood,
plywood, asbestos)
Others 6. Is there any electricity in the A. No 0
Paluwagan/MFI building/house? B. Yes 7
Insurance Premium 7. What is the family's main source of A. Other 0
water supply?
Other Loan Payments B. Dug well 5
Other Expenses (please specify)
C. Own use, faucet, community water 10
system

(C) TOTAL HOUSEHOLD EXPENSES D. Own use, tubed/piped deep well or 7

Tubed/piped shallow well
(D) NET INCOME (A-B-C)
E. Shared, faucet, community water system 7
(E) Weekly equivalent of daily net income
(F) *Weekly equivalent of monthly net income F. Shared, tubed/piped deep well 6
*If the monthly net income is negative convert it to weekly but if the monthly 8. Does the family own a A. No 0
Refrigerator/freezer? B. Yes 13
Net Income is positive, assign zero to weekly equivalent of monthly net income. 9. Does the family own a television set? A. No 0
(G) TOTAL NET INCOME (Weekly Net Income + E + F) B. Yes 11
10. Does the family own a washing A. No 0
DEBT CAPACITY ANALYSIS SCORE machine? B. Yes 8
(H) Amount Available for Debt Service (G)
(I) Adjusted Debt Capacity (ADC) of 35% (ADC = H x 35%) PPI Score:

Conducted by:

_____________________________________
FIELD CREDIT OFFICER
(Signature over Printed Name)

Validated by:

__________________________________ _____________________________________________
Senior FCO and/or BRANCH MANAGER AREA MANAGER and/or FIELD OPERATONS HEAD
(Signature over Printed Name) (Signature over Printed Name)

KCCDMFI Loan Application Form – Revised August 1, 2020