ARMED FORCES OF THE PHILIPPINES (AFP)  Active Personnel  New

 Pensioner  Reloan
SALARY LOAN APPLICATION FORM  Legal Beneficiary  Multiple

Instructions: PLEASE PRINT ALL INFORMATION LEGIBLY IN CAPITAL LETTERS. Indicate N/A in the fields which are not applicable.
I hereby apply for a loan in the amount of PESOS:
DESIRED AMOUNT: ________________________________________________________________________________________________________________________________________ (P_________________________)
for the following purpose (required):
 Training/Education  Home Renovation  Loan Buy-out
 Medical  Household Consumption/Needs  Others (please state) ________________________
for a term of: _________________________ months, which I promise to pay in accordance with the rules, regulations, terms and conditions of CITY SAVINGS BANK, INC. as stipulated in this application form, the Promissory Note
of even date, and such other documents executed together with this loan; all of which I certify to have read and understood clearly.

PERSONAL INFORMATION
Client Name (Last Name, Given and Middle Name)  Single  Married
Civil Status
 Widowed Separated

Date of Birth (mm/dd/yyyy) Birth Place Sex  Male  Female

Nationality Religion Mobile No.

TIN GSIS/SSS No. Email Address

Present Address (No./Street/Village/Barangay/District/Municipality/City/Town/Province) Zip Code

 Owned  Living with Parents  Company Quarters  Mortgaged Length of Stay ______ Years ______ Months
Ownership
 Living with Relatives  Rented  Others (specify): ________________________ Res. Tel. No.

Permanent Address (No./Street/Village/Barangay/District/Municipality/City/Town/Province) Zip Code

 Owned  Living with Parents  Company Quarters  Mortgaged Length of Stay ______ Years ______ Months
Ownership
 Living with Relatives  Rented  Others (specify): ______________________ Res. Tel. No.

SOURCE OF FUNDS
Employer Office Tel. No. & Local

Present Unit/
Office Email Address
Office Assignment Address

Rank Basic Monthly Salary PHP

Monthly Recurring
Branch of Service PHP
Allowance

Nature of Work AFP Serial No.

Date Entered Military

Pay Jurisdiction
Service/Employed

CAD/Enlistment/Re-Enlistment
Order Authority

PENSION INFORMATION (Applicable to AFP Pension Application)

Optional Compulsory
Monthly Pension:
Retirement Date Retirement Date

Finance Center/Source of Pension:

SPOUSE INFORMATION (REQUIRED FOR MARRIED)

Spouse’s Name (Last Name, Given and Middle Name) Date of Birth

Birth Place

Employer/Business Mobile No.

Position Email Address

Nature of Work/ Business Monthly Income USD/PHP

PRIVATE INFORMATION PROVISIONS FOR LOAN APPLICATION

The customer acknowledges and agrees that, in the course of his/her engagement with City Savings
Bank, Inc. (“CitySavings”), and throughout the term of his/her relationship with CitySavings may
receive or have access to Personal Information and/or Sensitive Personal Information and/or any
financial information of the of the customer which CitySavings may consider as relevant in evaluating
the engagement (hereinafter collectively referred to as “Private Information.”) the customer
expressly consents to the processing, collection, transmission, storage, disposal, use and disclosure
of Private Information by CitySavings for the following purposes:
a. to manage customer’s account(s), including endorsement to outsourced
collections service provider in case of default, any consultant, adviser, auditor,
counsel, agent, contractor or sub-contractor of CitySavings performing services for
the purpose of assisting or rendering services to CitySavings in the administration
or promotion of its lending business;
b. to confirm, update and enhance CitySavings’ records;
c. for statistical analysis, internally by CitySavings and/or any service provider it may
engage for the purpose;
d. to establish any identity or otherwise as required under applicable legislation;
e. to assess Borrower’s credit status on an on-going basis;
f. for marketing and promotional of CitySavings products; or
g. any other purpose, as considered necessary or appropriate by CitySavings
d. to any person to whom CitySavings proposes to assign or transfer of its rights and/or duties to the loan;
e. to any guarantor or person providing security in relation to Borrower’s obligation;
f. as required or permitted by law, regulation, court or any regulatory authority; or
g. as otherwise considered necessary or appropriate by CitySavings.
“Personal Information” as used herein means the information provided to CitySavings by or at the direction of Borrower, or to which
access was provided to CitySavings by or at the direction of Borrower wherein: (i) the identity of an individual is apparent or can be
reasonably and directly ascertained; or (ii) when put together with other information, would directly identify an individual.
“Sensitive Personal Information” as used herein means any Personal Information that: (i) pertains to an individual’s race, ethnic origin,
marital status, age, color, and religious, philosophical, or political affiliations; (ii) pertains to an individual’s health, education, genetic or
sexual life, or to any proceedings in court; (iii) is issued by government agencies peculiar to an individual, e.g., social security numbers
and health records; or (iv) is specifically established by an executive order or an act of Congress to be kept classified.
Furthermore, by signing this form, the Borrower understands and expressly waives his/her right under confidentiality laws, including but
not limited to RA 10173 or the Data Privacy Act of 2012, RA 1405, or The Law on Secrecy of Bank Deposits, RA 6426 or The Foreign
Currency Deposit Act and RA 8791 or the General Banking Law and their respective implementing rules and regulations and hereby
agrees and consents to the processing, storing, access to, or sharing of any Personal Data regarding any of his/her loans with CitySavings
as well as the CitySavings products, services, and channels which the Borrower has activated, enrolled in or availed of.

In each case, the processing of Private Information may continue after the termination of the loan
agreement. CitySavings may disclose the Borrower’s Private Information:

a. to a credit reference agency where it may be accessed by other financial institutions

to assist assessment of any application for credit made to CitySavings and for debt
tracing and fraud prevention;
 b. to its parent company or any of its affiliate or subsidiary;
c. to any consultant, adviser, auditor, counsel, agent, contractor or sub-contractor of
CitySavings performing services for the purpose of assisting or rendering services to
CitySavings in the administration or promotion of its lending business;

INSURANCE COVERAGE
HEALTH DECLARATION EXCEPTIONS TO THE ABOVE: (if left blank, this will be taken to mean as “NONE”)
Please read accordingly and fill out with the best of your knowledge. ______________________________________________________________________

I hereby warrant and declare to the best of my knowledge that in the date of the release of
my loan, I am currently well and possess sound health and am able to perform the usual
activities in the pursuit of my livelihood and that:
1. I am in good health - free from mental and physical impairment or deformities and that
within the last 2 years has not been diagnosed as suffering from diabetes, cancer,
cardiovascular or HIV - related diseases and has not been advised to have hospital treatment
or surgery.
2. I have not been advised of, treated for, or had any known indication of:
a) Metastatic cancer diagnosed and/or treated within the last five years of application or
enrollment for insurance.
b) End-stage kidney failure or chronic renal failure requiring dialysis.
c) Any major organ transplant.
d) Myocardial infarction (heart attack), coronary thrombosis (clog), coronary
disease requiring coronary artery by-pass surgery, or any related heart diseases.
e) Stroke, infarction of brain issue, hemorrhage and embolization from an extracranial source,
or any related cerebrovascular or neurological diseases.
BENEFICIARY INFORMATION
I understand that the bank is the irrevocable beneficiary of the life insurance benefit up
to the extent of the amount of my loan with CitySavings at the time of death. Any
amount of benefit in excess of my loan will be received by the individuals I am
designating as my beneficiaries. I understand that in the absence of a designated
beneficiary or if there is no surviving designated beneficiary at the time benefits will be
paid out, Insular Life, the insurer, will pay to the following classes of beneficiaries, in this
order of priority: widow or widower, surviving legitimate, legitimated, legally adopted
and recognized natural children; surviving illegitimate children without distinction;
surviving parents; surviving brothers and sisters of the full blood; or executors, and
administrators or assigns.

BENEFICIARIES (Please Indicate at least 2)

Name (Last, Given and TIN Sex Relationship to the Insured Contact No. Date of Birth (mm/dd/yyyy)
Middle Name)

ACKNOWLEDGEMENT
By affixing my signature below, I hereby: (a) declare that I have read and understood the foregoing Health Declaration and Private Information Provisions, (b) confirm that the foregoing
statements and answers are full, complete, and true; (c) confirm that my legitimate spouse is informed and manifested his/her consent to my loan application (d) confirm that the submitted
documents are authentic and its contents are accurate; (e) agree that the information shall be the bases of the issuance of any insurance for me and the Insurer shall not be liable for any
claim on account of illness, injury, or death, the cause of which was known prior to approval of my request for insurance and withheld or concealed in the above statements; and (f)
acknowledge that my premiums shall be deducted in FULL from my loan proceeds.

Name of Borrower: ________________________________________________________________ Signature of Borrower: __________________________________

Signed at ______________________________________________________________ this ____________ day of _____________________ 20_____

I certify that the applicant personally appeared before me, completed this application and presented his identification documents; that I verified his information and
signature in the loan application against the submitted documents, and that the applicant appeared to be in good health and free from any physical impairments,
except for the conditions, if any, that are observed as follows: ___________________________________________________________________________________

Signature over printed name of CSB Representative: _________________________________________________________________ Date: ____________________

——————————DO NOT WRITE BELOW THIS SPACE-FOR CITYSAVINGS USE ONLY——————————
NET PAY/PENSION VALIDATION CIF No: ____ REDEMPTION
1. MM/DD/YYYY:_________________(Php)_____________ LOAN INFO PLI Name: ________________________________________
2. MM/DD/YYYY:_________________(Php)_____________ Branch Name : ____ PLI Name: ________________________________________
3. MM/DD/YYYY:_________________(Php)_____________ Branch SOL ID : ____ PLI Name: ________________________________________
4. MM/DD/YYYY:_________________(Php)_____________ Scheme Code : ____ SERVICING
Group Code : ____ Branch Name:__________________Scheme Code________

APPROVED AMOUNT: _________________________________________________________________________________________________________ (P_________________________)

Application received and verified by: ________________________________________________________ Date: ____________________________

Remarks/Exceptions: _________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________
Approved by: ___________________________________________________________________________ Date: ____________________________
Remarks/Exceptions: _________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________

LOAN RELEASE AND REFUND INSTRUCTIONS

If my application is approved, I hereby authorize CITYSAVINGS to release the loan proceeds and/or any refund for loan overpayment via:
 Credit to my account with:  City Savings Bank  Union Bank of the Philippines Account number:
 Other designated account: ________________________________________________

Signature of Borrower: _____________________________________________________________ Date: ______________________

CERTIFICATION (for Army/Air Force/ GHQ/PenBen USE ONLY)

This is to certify that the applicant is under my paying jurisdiction.

Signature over printed name of AFP Officer: _________________________________________ Date: ______________________

Signature over printed name of AFP Officer: _________________________________________ Date: ______________________