Agency Name:

Agency BP Number:

MGO MAMASAPANO
1000032039

AGENCY REMITTANCE ADVICE

FORM A. List of employees with life and retirement premium remittance but without existing record / Reinstatement

Last Name
SALIK

First Name
ZENAIDA

Suffix

Middle
Name
PUNTUAN
indicate Full Middle Name

Residential
Address/
Zip Code
MANUNGKALING, MAMASAPANO, MAGUINDANAO, 9608

PLS PROVIDE COMPLETE RESIDENTIAL ADDRESS

(INCLUDING HOUSE NO., STREET, BARANGAY OR PUROK)
WITH ZIP CODE

If any or all of the employees listed above are new employees in that Agency,
please provide the above information in the appropriate column.
If any or all of the employees listed above are transferees,
please provide the information required in Form B

Mobile
Email
Civil
Number
Address
Gender Status
0915-9180-73 zhen_salik@yahoo.com
FEMALESINGLE

Date
Place
of Birth
of Birth
7/15/1989 PATINDEG

Basic
Monthly
Salary
9,723.00

Date of
Assumption
Status of
of Duty
Position Employment
12/29/2012 COMPUTERTemporary
not date of Appointment

Agency Name:
Agency BP Number:

Always indicate data

Always indicate data

AGENCY REMITTANCE ADVICE

FORM B. List of transferees ( Transfer In / Transfer Out )
Member BP
Number

Agency Name
Last Name

First Name

Suffix

Midlle Name

From

To

Date of Transfer
pls. indicate specific data

pls. indicate specific data

Salary

Position

Status of
Employment

Agency Name:
Agency BP Number:

Always indicate data

Always indicate data

AGENCY REMITTANCE ADVICE

FORM C. List of employees with salary adjustments for confirmation as

to correct amount of monthly salary and effectively date to be supplied below

Member BP
Number

Last Name

First Name

Suffix

MI

Always indicate data

Please use Service Record for updating of services from date of assumption of duty to present.
Limit Form C for updating of services from 7/1/2007 to present only.

Salary

Effectivity Date

pls. indicate specific data

Position

Status of
Employment

Agency Name:
Agency BP Number:

Always indicate data

Always indicate data

AGENCY REMITTANCE ADVICE

FORM D. List of employees with no premium remittance for 2 consecutive months

Member BP
Number
Always indicate data

Last Name

First Name

Suffix

MI

Reason 1
pls. select from below

Effectivity Date
pls. indicate specific data

1 Reason: please specify whether resigned/ retired/ deceased/ dismissed/ end of term/ dropped from the roll/ suspended
2 Updating of LWOP is only limited to present date. Please resend the request for the next succeeding periods until completely updated.

LWOP
Effectivity Date
From
To
pls. indicate specific data

Agency Name:
Always indicate data
Agency BP NumbeAlways indicate data

FOR AGENCY REMITTANCE ADVICE

FORM E. List of employees with changes / correction in their Personal Data
Member BP
Number
Always indicate data

Last Name
From
To

First Name
From

Always indicate data

To
Always indicate data

Suffix
From
To

Middle Name
From
To

Residential Address/Zip Code

From
To

Mobile Number
From
To

PLS PROVIDE COMPLETE RESIDENTIAL ADDRESS

(INCLUDING HOUSE NO., STREET, BARANGAY OR PUROK)
WITH ZIP CODE

Please attach scanned copy of the original NSO Birth Certificate including the NSO Official Receipt
Member must be in ACTIVE Service upon request.

Email Address
From
To

Civil Status
From
To

Date of Birth *
From
To

Place of Birth
From
To

Gender
From
To

BP NUMBER

SERVICE RECORD
(To Be Accoumplished By Employer)
NAME:

(If married women give also full maiden

(Surname)

(Given Name)

(Middle Name)

BIRTH:
DATE

(Data herein should be checked from birth

or baptismal certificate or some other

PLACE

This is to certify that the employee named hereinabove actually rendered

services in this Office as shown by the service record below, each line of which
is supported by appointment and other papers actually issued by this Office

SERVICE

(Inclusive dates)
From
To

RECORD OF APPOINTMENT
Designation

Employment

Salary

Status

OFFICE ENTITY/DIVISION
Station/Place

BRANCH

of assignment

LEAVE

SEPARATION

WITHOUT PAY
From

DATE

CAUSE

To

Issued in compliance with Executive Order No. 54 dated August 10, 1954 and in accordance with, Circular No. 58 dated August 10, 1954 of the System.
PREPARED BY:

CERTIFIED CORRECT:

(Chief or Head of Office)

(Designation)

(Designation)

Date

REMARKS

1954 of the System.

ADDITIONAL DEPENDENT FORM FOR CM POLICY ONLY

Agency Name:
Agency BP Number:

BP Number
Always indicate data

Always indicate data

Always indicate data

Name of Member
Last Name

First Name

Always indicate daAlways indicate data

Suffix

MI

Name of Beneficiaries

Relationship

Date of Birth