APPLICATION FOR HQP-PFF-285

(V08, 06/2023)

PROVIDENT BENEFITS (APB) CLAIM CLAIM FILE No.

(To be filled out by member/claimant. Print this form back to back on one single sheet of
paper)
TYPE OR PRINT ENTRIES
MEMBERSHIP PROGRAM  Pag-IBIG I  MODIFIED Pag-IBIG II (MP2)
MP2 Account/s No.:
REASON FOR CLAIM (Check appropriate box)
 MEMBERSHIP TERM MATURITY  CRITICAL ILLNESS OF THE MEMBER OR ANY OF HIS  DEATH
 RETIREMENT IMMEDIATE FAMILY MEMBER Date of Death
Effective Date of Retirement  Member  Immediate Family Member  EXPATRIATE
Last Day of Service Please specify type of illness:  MODIFIED Pag-IBIG II (MP2)
 PERMANENT TOTAL DISABILITY/INSANITY  OPTIONAL WITHDRAWAL  Maturity  Pre-Termination
 TERMINATION FROM SERVICE BY REASON  PERMANENT DEPARTURE FROM THE COUNTRY Please specify the reason of Pre-Termination:
OF HEALTH
MEMBER’S PERSONAL DETAILS
LAST NAME FIRST NAME NAME EXTENSION (e.g., Jr., II) MIDDLE NAME MAIDEN NAME Pag-IBIG MID No./RTN
(For married women)

DATE OF BIRTH MARITAL STATUS DESIRED AMOUNT (For optional withdrawal)

 Single/Unmarried  Widow/er  Annulled
 Married  Legally Separated ₱ / (%)
CLAIMANT, if other than the Member (Last Name, First Name, Name Extension, Middle Name) RELATIONSHIP TO MEMBER

ADDRESS AND CONTACT DETAILS

MEMBER’S PRESENT HOME ADDRESS MEMBER/CLAIMANT CONTACT DETAILS
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No. Street Name Subdivision COUNTRY + AREA CODE TELEPHONE
NUMBER
Barangay Municipality/City Province/State/Country (if abroad) ZIP Code Home

CLAIMANT’S PRESENT HOME ADDRESS (Leave blank if the same as member) Cell Phone (Required)
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No. Street Name Subdivision

Email Address
Barangay Municipality/City Province/State/Country (if abroad) ZIP Code

EMPLOYMENT DETAILS FROM DATE OF Pag-IBIG MEMBERSHIP (Use another sheet if necessary)
DATE OF Pag-IBIG MEMBERSHIP
EMPLOYER/BUSINESS NAME EMPLOYER/BUSINESS ADDRESS
FROM (Month/Year) TO (Month/Year)

AUTHORITY TO CREDIT
IN THE EVENT OF THE APPROVAL OF MY APPLICATION FOR PROVIDENT BENEFITS CLAIM, I HEREBY AUTHORIZE Pag-IBIG FUND TO CREDIT MY CLAIM PROCEEDS TO
MY PAYROLL ACCOUNT/DISBURSEMENT CARD THAT I HAVE INDICATED BELOW:
ACCREDITED PARTNER-BANK
PAYROLL ACCOUNT CARD DISBURSEMENT CARD PAYROLL ACCOUNT/DISBURSEMENT CARD NO.
 LANDBANK’S PAYROLL CREDIT SYSTEMS  LANDBANK CASHCARD  UNION BANK LOYALTY CARD PLUS
VALIDATION (PACSVAL)  DBP PREPAID CARD  AUB LOYALTY CARD PLUS
NOTE: SIGNATURE OF MEMBER DATE
In case the claim proceeds are higher than the maximum aggregate monthly credit amount of the concerned accredited partner-bank (as applicable),
the release of claim proceeds shall be through Check. The following are the maximum aggregate monthly credit amount of the concerned banks:
 Landbank CashCard - ₱500,000.00  AUB Loyalty Card Plus - ₱500,000.00
0

 Landbank PACSVAL - No Limit

 DBP Prepaid Card - ₱100,000.00 (Valid until 30 Nov. 2023)  Union Bank Loyalty Card Plus - No Limit

APPLICATION AGREEMENT
I hereby certify that I have read and understood the contents hereof, including the guidelines and instructions indicated at the back THUMBMARKS OF MEMBER/CLAIMANT
portion of this form. I likewise understand that the processing of this application is subject to pertinent provisions of the
(If unable to sign)
implementing rules and regulations of the Pag-IBIG Fund. In the event of any outstanding Pag-IBIG loan, Pag-IBIG Fund is
hereby authorized to withhold, in whole or in part, the provident benefit subject of this claim, and apply the same as payment to
the said loan as well as other obligations due to the Pag-IBIG Fund as of the date of this application.
I hereby waive my rights under R.A. No. 1405 (Secrecy of Bank Deposits Act) and authorize Pag-IBIG Fund to verify/validate my
payroll account/disbursement card.
LEFT THUMB RIGHT THUMB
I authorize Pag-IBIG Fund to disclose, submit and share or exchange any of my account information to legal and government
regulating agencies in accordance with R.A. No. 10173 (Data Privacy Act of 2012), and other related or pertinent laws and (To be done in the presence of Pag-IBIG Fund Personnel)
regulations, as described in Pag-IBIG Fund’s Freedom of Information (FOI) Manual.
I certify that the information given and any or all statements made herein are true and correct to the best of my knowledge and
belief. I hereby certify under pain or perjury that my signature appearing herein is genuine and authentic.
,,,

(Signature over Printed Name of Witness) Date

MEMBER/CLAIMANT
(Signature over Printed Name)

THIS PORTION IS FOR Pag-IBIG Fund USE ONLY

CLAIMS/HL/STL/LOYALTY CARD VERIFICATION
DV/CHECK/PN/APPLICATION/ DATE FILED/HL OUTSTANDING
PARTICULARS WITH WITHOUT AS OF VERIFIED BY DATE
HOUSING ACCOUNT No. TAKEOUT DATE BALANCE
CLAIMS
HOUSING LOAN
MULTI-PURPOSE LOAN
CALAMITY LOAN
HELPs
LOYALTY CARD
PAYEE/S (Use another sheet if necessary) REMARKS

RECEIPT OF APPLICATION
RECEIVED BY DATE REVIEWED BY DATE APPROVED BY DATE

DISAPPROVED BY DATE REMARKS

THIS FORM MAY BE REPRODUCED. NOT FOR

SALE
 HQP-PFF-285
(V08, 06/2023)

GUIDELINES AND INSTRUCTIONS

A. When to File
b. Filing of application through online
The Application for Provident Benefits Claim (APB) (HQP-PFF-285) may
be filed upon the occurrence of any of the following:
The online filing through Virtual Pag-IBIG shall be applicable to the
1. Membership Maturity - shall be based on 20 years of membership
following grounds only:
with the Fund, reckoned from the initial contribution that is recorded in
the database; provided, the member has remitted a total of 240
 Membership term maturity
monthly membership savings to the Fund at the time of maturity;
 Retirement
2. Retirement - a member shall be compulsorily retired under the Fund
 Optional withdrawal (15 years)
upon reaching the age of 65. A member may opt to retire earlier under
 Modified Pag-IBIG II (MP2) maturity
the Fund upon the occurrence of any of the following events:
a. Actual retirement from the SSS, GSIS, or from government service
1. Prepare photo/scanned copy of the following documents:
by provision of law;
b. Retirement under a private employer’s provident/retirement plan,
- Accomplished Application for Provident Benefits (APB) Claim
provided that the member is at least 45 years of age at the time of
- One (1) valid ID
retirement;
- Supporting documents
c. Reaching the age of sixty (60).
- Selfie photo showing ID card
3. Permanent Total Disability (PTD) or Insanity - PTD refers to the loss or
impairment of a physical or mental function resulting from injury or
2. Access the Virtual Pag-IBIG at the Pag-IBIG Fund website and file the
sickness, which incapacitates said member to perform any work or
application for provident benefits claim.
engage in any business or occupation;
4. Termination from Service by Reason of Health - a member can no
D. Payment of Benefits
longer render service to an employer due to severe health conditions,
as certified by his doctor;
1. Return of Total Accumulated Value
5. Critical Illness of the member or any of his immediate family member,
a. The TAV to be returned to the member or his legal heirs, less of any
as certified by a licensed physician, under any of the following
and all pending obligations with the Fund, shall consist of member’s
categories, subject to the approval of Deputy Chief Executive Officer -
remitted accumulated savings; employer’s counterpart savings, if
Member Services Cluster:
applicable; and dividend earnings credited to the member’s account as
a. Cancer
declared by the Board.
b. Organ Failure
b. For members with outstanding obligations with the Fund, at the time of
c. Heart-related Illness
termination of membership, the said obligation shall be deducted from
d. Stroke
his TAV prior to the release of the provident claim.
e. Neuromuscular-related illness
c. Release of member’s TAV shall be based on actual savings remitted
The immediate family member includes any of the following:
by the employee and employer, if applicable. In the case of member-
- Spouse
claimants whose employer counterpart savings have not been remitted
- Parent
to the Fund, a partial release of their TAV shall be made based on
- Children
actual amounts credited to their accounts. In the same manner, the
- Sibling
computation of annual dividends shall be based on actual remittances
- Grandparents
made. Any amount that the Fund may collect from the employer due to
- Grandchildren
enforcement shall be subsequently released to the member or his
- Legally adopted children shall only be included insofar as
heirs.
applications for withdrawal of savings of their approval mothers or
d. In case of member’s death, the release of his provident benefit claims
adoptive fathers;
shall be in accordance with the laws on succession.
6. Death;
e. A member who has multiple employers shall be entitled to claim his
7. Optional Withdrawal of Pag-IBIG Savings
entire savings anytime upon occurrence of any of the grounds for
a. Members of the Fund after the effectivity of R.A. 9679 shall have the
membership termination.
option to withdraw his or her TAV on the fifteenth (15 th) year of
continuous membership. This option may be exercised only once
2. Death Benefit
during the membership term;
b. A member eligible for optional withdrawal after completing 180
a. Upon the death of a member, his legal heirs shall be entitled to receive
continuous monthly savings may opt to withdraw an amount less
the applicable death benefit in addition to the deceased member’s
than the equivalent sum of said 180 monthly savings. The remaining
TAV. The amount of the death benefit shall depend on his membership
TAV together with succeeding savings shall be released to the
status with the Fund at the time of his death.
member upon the occurrence of any of the grounds for membership
- For active members at the time of death – P6,000, regardless of the
termination;
amount of TAV.
8. Permanent Departure from the Country - a member has been
- For inactive members at the time of death – the amount is equivalent
permitted by his host country to remain there indefinitely or has
to member’s TAV or P6,000, whichever is lower.
permanently left the Philippines to reside in another country;
- If TAV offsetting occurred prior to the member’s death – the amount
9. Expatriates;
10. Modified Pag-IBIG II (MP2); of death benefit to be granted shall depend on the membership status
as of date of death. In case of inactive status as of date of death, the
11. Any other reasons as may be approved for by the Board.
TAV under consideration shall be the TAV prior to offsetting.
b. The legal heirs of the deceased member shall still be entitled to death
B. Who May File
benefit, subject to the conditions set and under the following
circumstances:
The application may be filed by the member, his guardian, or any
- The check for provident benefit claims based on the grounds for
authorized representative/s. If the reason for claim is death of the member,
membership termination other than death is not yet released to the
the application may be filed by his heir/s or the latter’s representative/s, or
member;
any appointed court administrator or executor.
- The member’s provident benefit claim proceeds are not yet credited
to his disbursement/cash card or Payroll Account at the time of his
C. How to File
death.
a. Filing of application at the branch
3. Manner of Payment
1. Secure the Application for Provident Benefits (APB) Claim from any
a. Shall be paid to the member or his legal heirs through any of the
Pag-IBIG Fund branch or download from Pag-IBIG website at
following modes:
www.pagibigfund.gov.ph.
- Crediting to the claimant’s disbursement/cash card or Payroll Account;
2. Accomplish one (1) copy of the application form.
- Through check payable to the claimant; or
3. For releasing of claim proceeds through Payroll Account Card/
- Other similar modes of payment approved by the Board.
Disbursement Card, attach the photocopy of payroll
b. Claiming of checks through a representative shall be allowed provided
account/disbursement card/deposit slip for newly-opened account
the representative shall present the documents that the Fund may
(front portion of the card only).
require relative to the provident benefit claim.
4. Submit the accomplished application form, together with required
documents to any Pag-IBIG Fund branch. Processing of claim shall
commence only upon submission of complete documents.