EMP NAME

ADDRESS

PEN EMPLOYER TYPETEL # YEARINCHARGE MONTHPOSITION TYPE OF REPORTEMAIL DATE PREPARED# OF EE'S LAST NAME SUFFIX FIRST NAME

1 DE PAZ RUEL 2 SANTIAGO JEFFREY 3 VELASCO MALOU 4 GAPPI ROMMEL 56789101112131415161718192021222324252627282930313233343536373839404142

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1000

EMPLOYEE COUNT 4 SSS NUMBER ME-5 # / OR # TIN AMOUNT PAID

PRIVATE ALLOTED GS DATE PAID2015 PREPARED BY APPLICABLE MONTH

12 DESIGNATION TOTAL RF-1R OVER/UNDER

1/14/2016 3:57PHILHEALTH NO SEX SALARY SB

MIDDLE NAMEIBOJO 0CRUZ 0ALCANTARA 0RAYMUNDO 0

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TOTAL PS 0.00 LINKSTOTAL ES 0.00NO ALLOTED GS 0.00

DECEMBER TOTAL ARREARS 0.000.00 TOTAL PS & TOTAL ES 0.000.00 TOTAL PS + NO ALLOT 0.00

PS ES ALLOTED REMARKS DATE

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PRINT OUT RF1SAVE TXT

PRINT OUT RF1aSAVE TXTa

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Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518

Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518

Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518

Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518

Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518

Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518

Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518Err:518 Err:518 Err:518

REMITTANCE REPORT

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RF-1 EM THIS PORTION TO BE FILLED UP BY PHILHEALTH

PHILHEALTH NO. 000000000000

EMPLOYER TIN 0

COMPLETE EMPLOYER NAME EMPLOYER TYPE REPORT TYPE

COMPLETE MAILING ADDRESSDECEMBER 2015

TELEPHONE NO. 0 EMAIL ADDRESS 0

EMPLOYEE/S INFORMATION

LAST NAME FIRST NAME MIDDLE NAME PS ES

1 DE PAZ RUEL IBOJO 0 0 2 SANTIAGO JEFFREY CRUZ 0 0 3 VELASCO MALOU ALCANTARA 0 0 4 GAPPI ROMMEL RAYMUNDO 0 0 5 0 0 6 0 0 7 0 0 8 0 0 9 0 0 10 0 0 11 0 0 12 0 0 13 0 0 14 0 0 15 0 0 16 0 0 17 0 0 18 0 0 19 0 0 20 0 0 21 0 0

PHILHEALTH IDENTIFICATION NUMBER (PIN)

PHILHEALTH IDENTIFICATION NUMBER

(PIN)

Fill-out this portion only if declared employee/s has not yet been

issued his/her PIN

NHIP PREMIUM CONTRIBUTION

NAME SUFFIX

DATE OF BIRTH (mm-dd-yyyy)

DATE OF BIRTH (mm-dd-yyyy)

SEX (M/F)

MONTHLY SALARY

BRACKET (MSB)

S-Separated, NE-No Earnings, NH-Newly Hired / Effectivity Date

Revised January2012

1

6

2

7 8 9 10 11

3 4 5

Date Received: ________________________By :________________________

Signature Over Printed Name

Action Taken:

PRIVATE

GOVERNMENT

HOUSEHOLD

REGULAR RF-1ADDITION TO PREVIOUS RF-1DEDUCTION TO PREVIOUS RF-1

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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997 0 0 998 0 0 999 0 0 1000 0 0

ACKNOWLEDGEMENT RECEIPT (PAR/POR/TRANSACTION REFERENCE NO.)

GRAND TOTAL (PS+ES) 0.00 0.00

4 APPLICABLE PERIOD REMITTED AMOUNT ACKNOWLEDGEMENT RECEIPT TRANSACTION DATE

DECEMBER 0.00 0 (To be accomplished on every page) 0.00 1/14/2016 3:57

UNDER THE PENALTY OF THE LAW, I HEREBY ATTEST THAT THE ABOVE INFORMATIONS PROVIDED HEREIN ARE TRUE AND CORRECT.

Signature over printed name Official Designation Date

Indicate Total Number of employees per page

14 1512

16

13SIGNATURE OVER PRINTED NAME

OFFICIAL DESIGNATION

DATE

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THIS PORTION TO BE FILLED UP BY PHILHEALTH

DECEMBER 2015

EMPLOYEE STATUS

APPLICABLE PERIOD

S-Separated, NE-No Earnings, NH-Newly Hired / Effectivity Date

11

Action Taken:

This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 145 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 146 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 147 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 148 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 149 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 151 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 152 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 153 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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1/14/2016 3:57

UNDER THE PENALTY OF THE LAW, I HEREBY ATTEST THAT THE ABOVE INFORMATIONS PROVIDED HEREIN ARE TRUE AND CORRECT.

SIGNATURE OVER PRINTED NAME

OFFICIAL DESIGNATION

DATE

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RF-1 EMPL THIS PORTION TO BE FILLED UP BY PHILHEALTH

PHILHEALTH NO. 000000000000

EMPLOYER TIN 0

COMPLETE EMPLOYER NAME EMPLOYER TYPE REPORT TYPE

COMPLETE MAILING ADDRESSDECEMBER 2015

TELEPHONE NO. 0 EMAIL ADDRESS 0

EMPLOYEE/S INFORMATION

LAST NAME FIRST NAME MIDDLE NAME PS ES

1 DE PAZ RUEL IBOJO 0 0 2 SANTIAGO JEFFREY CRUZ 0 0 3 VELASCO MALOU ALCANTARA 0 0 4 GAPPI ROMMEL RAYMUNDO 0 0 5 0 0 6 0 0 7 0 0 8 0 0 9 0 0 10 0 0 11 0 0 12 0 0 13 0 0 14 0 0 15 0 0 16 0 0 17 0 0 18 0 0 19 0 0 20 0 0 21 0 0

PHILHEALTH IDENTIFICATION NUMBER (PIN)

PHILHEALTH IDENTIFICATION NUMBER

(PIN)

Fill-out this portion only if declared employee/s has not yet been

issued his/her PIN

NHIP PREMIUM CONTRIBUTION

NAME SUFFIX

DATE OF BIRTH (mm-dd-yyyy)

DATE OF BIRTH (mm-dd-yyyy)

SEX (M/F)

MONTHLY SALARY

BRACKET (MSB)

S-Separated, NE-No Earnings, NH-Newly Hired / Effectivity Date

Revised January2012

1

6

2

7 8 9 10 11

3 4 5

Date Received: ________________________By :________________________

Signature Over Printed Name

Action Taken:

PRIVATE

GOVERNMENT

HOUSEHOLD

REGULAR RF-1ADDITION TO PREVIOUS RF-1DEDUCTION TO PREVIOUS RF-1

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 175 OF 221 PAGES

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 176 OF 221 PAGES

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 177 OF 221 PAGES

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 178 OF 221 PAGES

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 187 OF 221 PAGES

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 188 OF 221 PAGES

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 189 OF 221 PAGES

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 190 OF 221 PAGES

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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997 0 0 998 0 0 999 0 0 1000 0 0

ACKNOWLEDGEMENT RECEIPT (PAR/POR/TRANSACTION REFERENCE NO.)

GRAND TOTAL (PS+ES) 0.00 0.00

4 APPLICABLE PERIOD REMITTED AMOUNT ACKNOWLEDGEMENT RECEIPT TRANSACTION DATE

DECEMBER 0.00 0 (To be accomplished on every page) 0.00 1/14/2016 3:57

UNDER THE PENALTY OF THE LAW, I HEREBY ATTEST THAT THE ABOVE INFORMATIONS PROVIDED HEREIN ARE TRUE AND CORRECT.

Signature over printed name Official Designation Date

Indicate Total Number of employees per page

14 1512

16

13SIGNATURE OVER PRINTED NAME

OFFICIAL DESIGNATION

DATE

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THIS PORTION TO BE FILLED UP BY PHILHEALTH

DECEMBER 2015

EMPLOYEE STATUS

APPLICABLE PERIOD

S-Separated, NE-No Earnings, NH-Newly Hired / Effectivity Date

11

Action Taken:

This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 197 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 198 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 199 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 200 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 201 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 204 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 207 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 208 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 209 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

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This form maybe reproduced and is NOT FOR SALE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 212 OF 221 PAGES

This form maybe reproduced and is NOT FOR SALE

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