Application Date: __________________

AMOUNT APPLIED: _____________________________________________________________________ (P _______________ ).

For PAAL Order items @ LIPIEMCO, specify your choice below: (i.e. brand, model, specs, color, etc.)

Item 1:Item 2:Item 3:Item 4:

TERM APPLIED: ___________

Credit Rate: _______________ Cash

MIGS Rate: ________________ Name of Bank: Account No:

Last Name: __________________________________________________________

Renting Property Owner: ________________ Owned

Yrs of Employment : __________________________Spouse Details:

Received Items for PAAL:

Name& Signature of Member/ BorrowerRemark/s:

MEMBER APPLICANT'S PROFILE

TO BE FILLED-UP BY THE EMPLOYER (IF EMPLOYED)

___________________________________________________________________________________________________________

___________________________________

# of Yrs of stay : ____________________

Middle Name : _____________________First Name : _____________________________________

Present/City Address : _________________________________________________________________________

Email Add : _________________________________________________________________

Employment Status : ___________________________

Contact No.__________________________________________

Member-Applicant's Name & Signature

Purpose: ________________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Living with Parents/Relatives

I/ We certify that (1) the above signature of the member/borrower is authentic (2) there is no pending admistrative and/or criminal charge against him/her. (3) the information reported by said member/borrower is true/ and correct.

Tel. +6332-520-9367/ 420-0917

PayrollDeductionPost Dated CheckMode of payment:

Contact No. :_________________________________________Spouse Name: _____________________________________________________________

LOAN DETAILS: _______________________________________________________________________________

REGULAR LOAN

PERSONAL DATA DISCLOSURE AUTHORIZATION

Date

Finance/ HR OfficerSIGNATURE OVER PRINTED NAME

___________________________________________________________________________________________________________

(4) the member is not on leave of absence without pay.

Employer Address : _______________________________________________________________________________________________________________

LOAN TYPE : Providential Loan Short Term Loan PAAL Motorcycle Loan Tuition Loan

LIPI EMPLOYEES MULTIPURPOSE COOPERATIVE (LIPIEMCO)

Unit 3 2nd Floor Maroo Realty Bldg. Mantawi

Int'l Drive, Subangdaku, Mandaue City

Employer : _______________________________________________________________________________________________________________________

LAF 0001

___________________________________________________________________________________________________________

Position : ____________________________________________

Revised| October 2015

Department :_________________________________________Name of Employer : _________________________________________________________Provincial Address : ______________________________________________________________________________________________________________

I hereby give consent to LIPIEMCO to collect and gather my personal data, to store and to process such data for the purpose of availing products and services from LIPIEMCO, and sharing such data to Philippine Cooperative Central Fund Federation, for its iMCOOP and for coop analytics. I hereby acknowledge and authorize: 1) the regular submission and disclosure of my basic credit data (as defined under Republ ic Act No. 9510 and its Implementing Rules and Regulations) to the Credit Information Corporation (CIC) as well as any updates or correc tions thereof; and 2) the sharing of my basic credit data with other lenders authorized by the CIC, and credit reporting agencies d uly accredited by the CIC. I further consent the pulling and disclosure of my credit report and score from the CIC and CIBI Information Inc to establish my creditworthiness and in relation to my loan application and management. I further authorize the use of my credit data and rep ort by CIBI Information for Coop Analytics and Credit Bureau purposes.

1. LOAN GRANTED (A)2. FINANCE CHARGES

a. Service Feeb. Commitment Feec. Other Charges

TOTAL FINANCE CHARGES (B)

3. NON-FINANCIAL CHARGESa. Insurance Premium

b.

c. Retentiond. Others (Loans)

TOTAL NON- FINANCE CHARGES (C)

_____________ (D)

Date

Checked by:

(As required under RA No. 3765, the "Truth In Lending Act")

Spcl Savings

Loan guarantee

4. TOTAL DEDUCTION

FROM Proceeds of Loans (B

DISCLOSURE STATEMENT ON LOAN/ CREDIT TRANSACTION

Prepared BY:

Credit Committee

Approved By:

Confirmation by CreCom

Credit Committee

Credit Committee

THEREOF.

thereof, the same to be considered liquidated damages.the amount due and payable for every thirty(30) days or fractionAn additional amount equivalent to and computed at _______ % of

Credit Committee

Name & Signature of Borrower

LIPI EMPLOYEES MULTIPURPOSE COOPERATIVE (LIPIEMCO)

Unit 3 2nd Floor Maroo Realty Bldg. Mantawi

Int'l Drive, Subangdaku, Mandaue City

Tel. +6332-5209367/ 420-0917

I/ WE ACKNOWLEDGE RECEIPT OF THIS STATEMENT PRIOR TO THE

CONSUMMATION OF THE CREDIT TRANSACTION AND THAT WE

UNDERSTAND AND FULLY AGREE TO THE TERMS AND CONDITIONS

5. NET PROCEEDS: A less D

b. Total installment payments payable in ______________.a. Single Installment due on ___________7. SCHEDULE OF PAYMENT6. Interest Rate: ______ % per month

NOT MET BY BORROWER:9. ADDITIONAL CHARGES IN CASE CERTAIN STIPULATIONS ARE

________ Chattel Mortgage________ Real Estate Mortgage

This loan is wholly/partial secured by: 8. COLLATERAL

LIPI EMPLOYEES MULTIPURPOSE COOPERATIVE (LIPIEMCO) Unit 3, 2nd Floor Maroo Realty Bldg. Mantawi Int’l Drive, Subangdaku, Mandaue City

Tel. No : 520-9367/ 420-0917 FORM NO. 002

PROMISSORY NOTE

PN Number :

Date of Note :

Maturity Date :

For VALUE RECEIVED, I/We promise to pay, jointly and severally to the order of LIPI EMPLOYEES MULTIPURPOSE COOPERATIVE (LIPIEMCO) the sum in PESOS: ***_______________________________________________________(Php_________________), plus interest in the rate of _____% per annum, payable in installments of __________________________________________________ (Php ___________________) the first payment to be made on _________________ and a like amount every installment period until the full amount is fully paid. The obligation contracted in this Note is resulting from a loan granted by LIPIEMCO to me/us. This note is subject to a Real Estate or Chattel Mortgage, if applicable, to be executed by me/us to secure this loan. Failure on my part to apply the said amount to the purpose for which it is granted would render the whole amount of the loan due and demandable. In case of any failure or default in payments as herein agreed or failure on my/our part to make prompt payment on any of the monthly stipulated due dates shall render the entire amount of loan or the balance thereof due and demandable. Each party to this note whether as a maker, co-maker, endorser or guarantor; severally waive presentation of payment, demand protest and notice of protest of the same. Any partial payment or performance of this note or any extension thereof granted shall neither alter, novate nor vary the original terms of the obligation not discharge, and such partial payment of performance shall be considered as written acknowledgement of this obligation which interrupts the period of prescription.

To further secure this loan, I hereby pledge and assign to LIPIEMCO my salary and wage, savings/time Deposits/Share Capital, patronage refunds and interest on Share Capital. In case of my separation or resignation from ________________________________________________ employment before full payment of this loan, I likewise pledge and assign my retirement or separation pay, pension including but not limited to our advance pension, if any. For this purpose, I hereby appoint and designate with the understanding not to revoke this appointment/ designation without written authority of LIPIEMCO, my employer or attorney-in-fact, to pay the loan by deducting or collecting from any or all of the aforementioned income due to me in such amount as to satisfy the principal, interest and penalties, if any, on said loan. It is further agreed that in case payment shall not be made at maturity, I shall pay a penalty for 2% per month plus collection cost, and attorney’s fees in addition to the principal and interest due

on this note. Such charge in no event to be less than ONE THOUSAND PESOS (php 1,000.00) and that said suit shall be subject to the jurisdiction of the courts of Cebu City, or Mandaue City. In witness whereof, I/We hereunto signed this instrument this ______ day of ______________________ at ________________, Philippines. With my marital consent: ________________________________ ________________________________

Name and Signature of Maker Spouse Name & Signature

ID No. __________________

CO – MAKERS

1. ______________________________ 2. ______________________________

Signature over the Printed Name Signature over the Printed Name ID No. __________________ ID No . _____________________ Contact No.: _____________________ Contact No.: _____________________

Address: _____________________ Address: _____________________

Amount: Php ___________

LIPI EMPLOYEES MULTIPURPOSE COOPERATIVE (LIPIEMCO) Unit 3, 2

nd Floor Maroo Realty Bldg., Mantawi Int’l Drive, Subangdaku, Mandaue City

Tel. 6332-520-9367 / 420-0917 Loan Form – 007

CO-MAKER STATEMENT WITH AUTHORITY TO DEDUCT

I, _____________________, agree to become the CO-MAKER of Mr./Mrs./Ms._______________________________

voluntarily signed this co-maker statement for the loan amount not exceeding _____________________ (Php

__________________) for the period of ________ month (s) / year (s). I further agree to voluntarily and

willingly bind myself to pay jointly and severally or solidarily all his/her unpaid obligations to LIPIEMCO,

according to the terms and conditions of Promissory Note which I signed in case he/she fails to pay his/her

obligations for whatever reason.

With this, I hereby authorized ______________________ to deduct from my salaries, bonuses, separation pay,

(Name of Company)

final salary, retirement benefits or whatever monetary grants, the amount due including interest and

penalties at the request of LIPIEMCO if this loan is not paid by Borrower.

Furthermore, I hereby permit the coop to withhold the release of my Share Capital contribution until such

time the principal borrower has found my replacement as co-maker or has paid in full his/her obligation.

Upon my membership termination, I hereby authorize LIPIEMCO to offset the borrower’s outstanding

obligation from my share capital contribution and last claims.

This authorization shall be effective until full payment of the loan herein contracted.

______________________________________

Co-maker signature over printed name / Date

Co-Maker’s Additional Information

Email Address Personal Tel. Number/

Mobile Number Present Address Permanent Address

CO-MAKER STATEMENT WITH AUTHORITY TO DEDUCT

I, _____________________, agree to become the CO-MAKER of Mr./Mrs./Ms._______________________________

voluntarily signed this co-maker statement for the loan amount not exceeding _____________________ (Php

__________________) for the period of ________ month (s) / year (s). I further agree to voluntarily and

willingly bind myself to pay jointly and severally or solidarily all his/her unpaid obligations to LIPIEMCO,

according to the terms and conditions of Promissory Note which I signed in case he/she fails to pay his/her

obligations for whatever reason.

With this, I hereby authorized ______________________ to deduct from my salaries, bonuses, separation pay,

(Name of Company)

final salary, retirement benefits or whatever monetary grants, the amount due including interest and

penalties at the request of LIPIEMCO if this loan is not paid by Borrower.

Furthermore, I hereby permit the coop to withhold the release of my Share Capital contribution until such

time the principal borrower has found my replacement as co-maker or has paid in full his/her obligation.

Upon my membership termination, I hereby authorize LIPIEMCO to offset the borrower’s outstanding

obligation from my share capital contribution and last claims.

This authorization shall be effective until full payment of the loan herein contracted.

______________________________________

Co-maker signature over printed name / Date

Co-Maker’s Additional Information

Email Address Personal Tel. Number/

Mobile Number Present Address Permanent Address