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2.
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6.
7.
8.
9.
10.
11.
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13.
14.
15.
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40.
No. of Employees Total No.of Employees TOTAL FOR
on this page if last page THIS PAGE P P P
GRAND TOTAL
FOR Pag-IBIG USE ONLY (if last page) P P P
PFR/VALIDATION No. DATE AMOUNT
MM DD YY
P
CERTIFIED CORRECT BY:
COLLECTING BANK REMARKS SIGNATURE OVER PRINTED NAME DATE
10 11 1. 12 13 14 15
9 Indicate the telephone number/s of the employer.
2.
3.
7.
8.
11 Indicate employee’s birth date in numeric format. Example March 20,
9. 1956, shall be written as 03/20/56.
10.
11.
12.
12 List the name of your employees. This may be for the purpose of registering
13. your employees for Pag-IBIG membership or for remitting contributions.
14.
15. 13 Indicate the amount of employee contributions. Do not round off nor drop
16.
centavos.
17.
18.
19.
14 Indicate the amount of employer counterpart contributions. Do not round off
20. nor drop centavos.
21.
24.
27.
17 Indicate the total number of employees listed if this is the last page of the
28.
29.
listing.
30.
34.
total amount of employee and employer contributions (under column 15 )
35. for this page.
36.
37. 19 Indicate the grand total of employee contributions (under column 13 ), the
38.
grand total of employer contributions (under column 14 ) and the grand
39.
COLLECTING BANK
MM DD YY
P
REMARKS SIGNATURE OVER PRINTED NAME
CERTIFIED CORRECT BY:
DATE
20 Indicate the number of this page.
TICKET DATE RECONCILED BY CHECKED BY OFFICIAL DESIGNATION PAGE NO. NO. OF PAGES
MM DD YY 20 21