PSU FORM 111

REQUEST FOR DELETION OF DEDUCTION

DIVISION NAME/CODE:
STATION NAME:

REGION V - BICOL REGION

CLUSTER 8

(School for Secondary/Distict for Elementary)

STATION CODE: (3 Digits)

267

EMPLOYEE NUMBER:

4819832

COMPLETE NAME:

RONNIE VIDOR VALLADORES JR

EMPLOYEES SIGNATURE:

NAME OF DEDUCTION

PARAMOUNT LIFE AND GENERAL INSURANCE CORPORATION

DEDUCTION CODE

20160 PARAMOUNT LGIC REG PL

AMOUNT OF DEDUCTION

P350

POLICY NUMBER
DATE DEDUCTION STARTED
(In the Payroll)
REASON FOR DELETION

4/1/2016
FINANCIAL PURPOSES

REQUIREMENTS:
1. ATTACH CERTIFICATION OF NO OBLIGATION FROM THE COMPANY (FOR LOANS)
2. STAMP RECEIVED BY AGENCY CONCERNED ON THE SPACE PROVIDED BELOW
THIS FORM (FOR INSURANCE, MEMBERSHIPS AND ETC.)
3. ATTACH PAYSLIP

(STAMP RECEIVED BY COMPANY CONCERNED)