Government Forms
Government Forms
Government Forms
REMINDERS:
PHILHEALTH IDENTIFICATION NUMBER (PIN)
1. Your PhilHealth Identification Number (PIN) is your unique and permanent
PURPOSE:
number.
2. Always use your PIN in all transactions with PhilHealth. REGISTRATION UPDATING/AMENDMENT
3. For Updating/Amendment check the appropriate box and provide details to Preferred KonSulTa Provider
be accomplished and submit corresponding supporting documents.
4. Please read instructions at the back before filling-out this form.
I. PERSONAL DETAILS
NAME NO
MIDDLE MONONYM
LAST NAME FIRST NAME EXTENSION MIDDLE NAME NA ME
(Jr./Sr./III)
(Check i f app li cable onl y)
MEMBER
MOTHER’s
MAIDEN NAME
SPOUSE
(If Married)
m m d d y y y y
SEX CIVIL STATUS CITIZENSHIP TAX PAYE R IDE NTIFICATION NUMBER (TIN) (Optional)
Male Single Annulled FILIPINO FOREIGN NATIONAL
Female Married Widow/er
Legally Separated
DUAL CITIZEN
Subdivision Baranga y Municipality/City Province/Sta te/Country (If abroad) ZIP Code E-mail Address (Required for OFW)
DATE OF NO Chec k if
NA ME MIDDLE MONONYM
BIRT H with
LAST NAME FIRST NAME EXTENSION
(Jr./Sr./III)
MIDDLE NAME RELATIONSHIP
(mm-dd-yyyy)
CITIZENSHIP NA ME Per manent
Disa bility
(Check i f app li cable onl y)
Correction of Sex
As necessary for the proper execution of processes related to the legitimate and Full Name:
declared purpose;
The use or disclosure is reasonably necessary, required or authorized by or under the ______________________________
law; and,
Adequate security measures are employed to protect my information. PRO/LHIO/Branch:
_____________________________
INSTRUCTIONS
1. All information should be written in UPPER CASE/CAPITAL LETTERS. If the information is not applicable, write “N/A.”
2. All fields are mandatory unless indicated as optional. By affixing your signature, you certify the truthfulness and accuracy of all
information provided.
3. A properly accomplished PMRF shall be accompanied by a valid proof of identity for first time registrants, and supporting
documents to establish relationship between member and dependent/s for updating or request for amendment.
4. On the PURPOSE, check the appropriate box if for Registration or for Updating/Amendment of information.
5. Indicate preferred KonSulTa provider near the place of work or residence.
6. For PERSONAL DETAILS, all name entries should follow the format given below. Check the appropriate box if registrant has no
middle name and/or with single name (mononym).
INSTRUCTIONS
1. Accomplish this form in one (1) copy only. If registration is thru online, the form 6. Indicate the full name of your FATHER and MOTHER as they appear in your birth certificate.
should be printed back to back on a single sheet of paper. 7. On the “OCCUPATION” portion, indicate your job, profession, or type of work to earn a living.
2. Type or print all entries in BLOCK or CAPITAL LETTERS. 8. On the “HEIRS” portion, the provision on the Laws on Succession, under the New Civil Code,
3. All fields marked with asterisk (*) are mandatory. shall be observed.
4. On the “OCCUPATIONAL STATUS” portion, if not employed or purpose is 9. For any subsequent change of information, please secure and accomplish Member’s Change
pre-employment, select “UNEMPLOYED/NOT YET EMPLOYED”. of Information Form (MCIF, HQP-PFF-049) and submit to any Pag-IBIG Branch nearest you.
5. The “NAME EXTENSION” shall refer to JR., II, III and the like.
*MEMBER
FATHER
EMPLOYEE NUMBER
*SEX HEIGHT WEIGHT PROMINENT DISTINGUISHING FACIAL FEATURES
Male (Ex. Moles, Scars, etc.)
Female ______ (cm) ______ (kg) For AFP/PNP Employee, Serial/Badge No.
Subdivision Barangay Municipality/City Province/State/Country (if abroad) ZIP Code Business (Trunk Line) Local
Email Address
*PREFERRED MAILING ADDRESS
Present Home Address Permanent Home Address Employer/Business Address
THIS FORM MAY BE REPRODUCED. NOT FOR SALE.
HQP-PFF-039
(V08, 11/2020)
PRESENT EMPLOYMENT DETAILS (If with more than one (1) employer, use separate sheet and follow format below)
*OCCUPATION EMPLOYMENT STATUS TYPE OF WORK (For OFW only)
(Pls. specify country of assignment)
Permanent/Regular Contractual Part-time/
Casual Project-based Temporary
Land-based __________________________
Sea-based __________________________
*EMPLOYER/BUSINESS NAME MONTHLY INCOME
Basic
+
*EMPLOYER/BUSINESS ADDRESS Allowances/Others
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No. =
Total Mo. Income
Street Name Subdivision Barangay OFFICE ASSIGNMENT
Head Office Branch ____________
Municipality/City Province State/Country (If abroad) ZIP Code DATE EMPLOYED (Month, Year)
PREVIOUS EMPLOYMENT FROM DATE OF Pag-IBIG Fund MEMBERSHIP (Use another sheet if necessary)
EMPLOYER/BUSINESS NAME OFFICE ASSIGNMENT
Head Office Branch ____________
EMPLOYER/BUSINESS ADDRESS FROM TO
m m y y y y m m y y y y
EMPLOYER/BUSINESS NAME OFFICE ASSIGNMENT
Head Office Branch ____________
EMPLOYER/BUSINESS ADDRESS FROM TO
m m y y y y m m y y y y
EMPLOYER/BUSINESS NAME OFFICE ASSIGNMENT
Head Office Branch ____________
EMPLOYER/BUSINESS ADDRESS FROM TO
m m y y y y m m y y y y
HEIRS (In case of death, Fund benefits shall be divided among the member’s heirs in accordance with the Rules of Succession under the New Civil Code, as amended) (Use another sheet if necessary)
m m d d y y y y
m m d d y y y y
m m d d y y y y
m m d d y y y y
CERTIFICATION
I hereby certify that the information given, and all statements made herein are true and correct. Likewise, I hereby authorize Pag-IBIG Fund to collect
record, organize, update/modify, consult, use, consolidate, block, erase or destruct my personal data as part of my information. I hereby affirm my
right to: (a) be informed; (b) object to processing; (c) access; (d) rectify, suspend or withdraw my personal data; (e) damages; and (f) data portability
pursuant to the provision of R.A. No. 10173 (Data Privacy Act of 2012).
______________________________________ _________________
SIGNATURE OF INFORMANT DATE
DISCLAIMER
Membership registration with the Fund does not automatically qualify a Pag-IBIG member to avail of the Fund’s various loan programs. A Pag-IBIG
member must satisfy the eligibility requirements and comply with the documentary requirements, which is subject to verification and approval.
HQP-PFF-093
(V04, 01/2019)
________________
Date
Dear Sir/Madam:
I would like to request for the consolidation/merging of my membership records with the
following information:
_______________________________ __________________________________
Member’s Name and Signature Name and Designation of Authorized Signatory
Approved by:
__________________________________
Name and Designation of Authorized Signatory