1. 8/17/13 MEMBER'S DATA FORM (MDF) PRINT (NO. 913229797650)
https://www.pagibigfundservices.com/PubReg/ViewPrint/MDFNew.aspx?AD7DE1AEB17251A7F6AED3DD075645DC3F9F3EB37E53E04508AA36EDF62… 1/2
MEMBER'S DATA
FORM (MDF)
FOR HDMF USE ONLY
Pag-IBIG MID No.
Registration Tracking No.
913229797650
INSTRUCTIONS
1. The Member's Data Form (MDF) shall be accomplished in two(2) copies. 6.
On the 'BENEFICIARIES' portion, the provision on the intestate
Succession, as Provided in the New Family Code shall be observed.
a. SINGLE - Mother, Father, Brother and/or Sister.b. MARRIED - Spouse,
Son, Daughter, Mother and Father
2. Type or print all entries in BLOCK or CAPITAL LETTERS.
3. The 'NAME EXTENSION' shal refer to JR., II, II and the like.
4. Indicate the full name of your FATHER and MOTHER as they appear in
you birth certificate. 7. Submit MDF in two (2) copies and present at least one (1) valid primary ID.
5. Accomplish only the 'PERMANENT HOME ADDRESS' if it is different
with the 'PRESENT HOME ADDRESS'.
8. For any subsequent change of information, please secure and accomplish
two (2) copies of the Member's Change of Information Form (MCIF)
[FPF110] and submit to the concerned HDFM Branch.
MEMBERSHIP CATEGORY
EMPLOYED PRIVATE SELF-EMPLOYED NOT YET EMPLOYED
EMPLOYED GOVERNMENT EMPLOYED PRIVATE HOUSEHOLD
OVERSEAS FILIPINO WORKER (OFW) INDIVIDUAL PAYOR
LAST NAME FIRST NAME
NAME
EXTENSION
(e.g. Jr., II)
MIDDLE NAME
NO MIDDLE NAME
(check if applicable
only )
MEMBER LEETIAO ERVIN INDOSO
FATHER LEETIAO ERNESTO DE LOS REYES
MOTHER (Maiden Name) LEETIAO RUTCHI INDOSO
SPOUSE (If Married)
MEMBERS'S NAME AS APPEARING
IN THE BIRTH CERTIFICATE
LEETIAO ERVIN INDOSO
DATE OF BIRTH
JANUARY 24, 1992
MARITAL STATUS
SINGLE
TAXPAYERS IDENTIFICATION NO.
SSS NUMBER
0727783503
GSIS NUMBER
EMPLOYEE NUMBER
For AFP/PNP Employee, Serial/Badge No.
For DECS Employee, Division Code-Station
Code
-
PLACE OF BIRTH
BACOLOD CITY, NEGROS
OCCIDENTAL
CITIZENSHIP
FILIPINO
SEX
MALE
PROMINENT DISTINGUISHING FACIAL FEATURES
COMMON REFERENCE NUMBER (CRN) (If Available)
PRESENT HOME ADDRESS CONTACT DETAILS
Unit/Floor/Room No. Building (Indicate countrycode if abroad)
COUNTRY + AREA CODE TELEPHONE NUMBER
Home
+63 6100 4467794
Cell Phone
+63 0912 8374968
Business (Direct Line)
Business (Trunk Line)
Email Address
ervin.i.leetiao@gmail.com
Lot No. Block No. Phase No. House No. Street
6 2 EARL CAROL ST
Subdiv ision Barangay
FRIENDSVILLE SUM-AG
Municipality /City Prov ince/State(if abroad)
BACOLOD CITY NEGROS OCCIDENTAL
Counry (if abroad) ZIP Code
PHILIPPINES 6100
PERMANENT HOME ADDRESS
Unit/Floor/Room No. Building Lot No. Block No. Phase No.
6 2
House No. Street Subdiv ision Barangay

2. 8/17/13 MEMBER'S DATA FORM (MDF) PRINT (NO. 913229797650)
https://www.pagibigfundservices.com/PubReg/ViewPrint/MDFNew.aspx?AD7DE1AEB17251A7F6AED3DD075645DC3F9F3EB37E53E04508AA36EDF62… 2/2
EARL CAROL ST FRIENDSVILLE SUM-AG
Municipality /City Prov ince Zip Code
BACOLOD CITY NEGROS OCCIDENTAL 6100
PREFERRED MAILING ADDRESS Present Home Address Permanent Home Address Employer/Business Address
EMPLOYMENT/BUSINESS DETAILS
EMPLOYER/BUSINESS NAME EMPLOYMENT STATUS
Permanent/Regular Contractual
Casual Project-based
Part-time/Temporary
EMPLOYER/BUSINESS ADDRESS
Unit/Floor/Room No. Building
DATE STARTED
Lot No. Block No. Phase No. House No. Street MONTHLY INCOME
Basic
Allowances/Others
Gross
Subdiv ision Barangay
Municipality /City Prov ince/State(if abroad)
OCCUPATION
Counry (if abroad) ZIP Code
TYPE OF WORK (For OFWs only)
Land-based Sea-based
MANNING AGENCY (To be accomplished by the seafarers only) ASSIGNED COUNTRY (Land-based only)
PREVIOUS EMPLOYMENT FROM DATE OF Pag-IBIG FUND MEMBERSHIP
EMPLOYER/BUSINESS NAME FROM TO
EMPLOYER/BUSINESS ADDRESS
EMPLOYER/BUSINESS NAME FROM TO
EMPLOYER/BUSINESS ADDRESS
HEIRS (In case of death, Fund benefits shall be divided among the member's legal heirs in accordance with the New Civil Code as amended by the New Family Code)
LAST NAME FIRST NAME
NAME
EXTENSION
MIDDLE NAME
NO MIDDLE NAME
(Check only if applicable)
RELATIONSHIP DATE OF BIRTH
LEETIAO RUTCHI INDOSO M OTHER M ARCH 9, 1964
LEETIAO KARL ANGELO INDOSO BROTHER NOVEM BER 21, 2002
I HEREBY CERTIFY THAT THE INFORMATION GIVEN AND ALL STATEMENTS MADE HEREIN ARE TRUE AND CORRECT.
SIGNATURE OF MEMBER 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.