HQP-PFF-053

MEMBERSHIP SAVINGS Pag-IBIG EMPLOYER'S ID NUMBER

REMITTANCE FORM (MSRF) 202730380008

NOTE: PLEASE READ INSTRUCTION AT THE BACK

EMPLOYER/BUSINESS NAME

JEREMIAS C GARCIA ACCOUNTING OFFICE

EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No Street Name
456 ORTIZ APT MAHARLIKA HWY
Subdivision Barangay Municipality/City Province/State/Country (if abroad) Zip Code

DICARMA CABANATUAN CITY NUEVA ECIJA 3100

NAME OF EMPLOYEES MEMBERSHIP CONTRIBUTIONS
ACCOUNT NAME EXT. Middle Name PERIOD MONTHLY EE ER REMARKS
Pag-IBIG MID NO. MEMBERSHIP
NO. COVERED COMPENSATION
PROGRAM Last Name First Name TOTAL
(JR., III, ETC) SHARE SHARE

121222993129 Pag-IBIG I AQUINO LORRAINE CORRALES 201809 Php 8,500.00 100.00 100.00 200.00
121037272333 Pag-IBIG I FRANCISCO JHOANA PARICA 201809 Php 14,000.00 100.00 100.00 200.00
121223923323 Pag-IBIG I FRANCISCO RAFFY KENNETH PARICA 201809 Php 9,000.00 100.00 100.00 200.00
121224080406 Pag-IBIG I GARCIA ERWIN GARCIA 201809 Php 8,000.00 100.00 100.00 200.00
121067008123 Pag-IBIG I GROSPE DANNIEN DOMINGO 201809 Php 12,500.00 100.00 100.00 200.00
121231522696 Pag-IBIG I DANIPOG EDUARDO CAYSIP 201809 Php20,000.00 100.00 100.00 200.00

TOTAL FOR THIS PAGE 600.00 600.00

GRAND TOTAL (if last page) 600.00 600.00 Php 1,200.00
EMPLOYER CERTIFICATION

I hereby certify under pain of perjury that the information given and all statements made herein are true and correct to the best of my knowledge and belief. I further
certify that my signature appearing herein is genuine and authentic.

JHOANA P. FRANCISCO LEGAL & ACCOUNTING STAFF September 26, 2018

HEAD OF OFFICE OR AUTHORIZED REPRESENTATIVE DESIGNATION/POSITION DATE
(Signature Over Printed Name)

THIS FORM MAY BE REPRODUCED. NOT FOR SALE (V03, 10/2016)

1
F1-Pag-IBIG 1 D-Deceased
F2-Pag-IBIG 2 L-Leave Without Pay/AWOL
M2-Modified Pag-IBIG 2 N-Newly Hired
RS-Resigned
RT-Retired