Republic of the Philippines

PROVINCE OF ZAMBOANGA DEL NORTE

MUNICIPALITY OF TAMPILISAN
DISBURSEMENT VOUCHER No.
MODE OF Check Cash Other
PAYMENT TIN/Employee No.: Obligation Request No.
PAYEE PHILHEALTH
RESPONSIBILITY CENTER
ADDRESS Dipolog City
Office/Unit/Project: Code:
EXPLANATION AMOUNT
Payment of Philhealth Contribution for the New Hired and Elective Employees for the Month of
February 2014, per supporting papers hereto attached in the total amount of……… Php 6,250.00

Total Php 6,250.00

CERTIFIED: CERTIFIED:
Allotment obligated for the purpose as indicated
Supporting documents complete and paper Funds Available
Signature Signature
Date: Printed Date:
Printed Name SHERRY LOU P. DAPROSA OLIVIA G. EBORDE
Name
Municipal Accountant Municipal Treasurer
Position Position
(Head,Accounting Unit/Authorized Representativ (Head,Treasury Unit/Authorized Representative)
APPROVED FOR PAYMENT: RECEIVED PAYMENT:

Signature Check No.: Bank Name: Date:

Printed Date: Signature Date:
ANGELES R. CARLOTO II
Name Printed Name PHILHEALTH Date:
Municipal Mayor OR. No./Other Documents JEV NDate:
Position
(Local Chief Executive/Authorized Representativ
FOR ACCOUNTING/PRE-AUDIT PERSONNEL USE ONLY:
CHECKLIST: MANDATORY MINIMUM SUPPORTING DOCUMENTS FOR COMMON TRANSACTIONS
(Maintenance & Other Operating Expenses/Capital Outlay)
Claims for Repairs:
3.h Repairs thru negotiated procurement and competitive bidding refer to Nos._____ and______, except Plans &
Specification.
Job Order / Contract
Waste Material Report
Certification that damage is due to fair wear
and tear and not due to negligence, by
Motorpool Incharge
Pre-Repair Inspection Report
Post-Repiar Inspection Report
Certification of the Motorpool Incharged of
their inability to repair.
3.I Other Claims
Statement of Account/Bill
Other Reasonable supporting documents
Reviewed by:

Name/Signature-Pre-Audit Section
Date:_______________________
 Republic of the Philippines FOR PHILHEALTH USE
PHILIPPINE HEALTH INSURANCE CORPORATION Date Screened: Action Taken: Date Received: Action Taken:By:
EMPLOYER'S QUARTERLY By: By:
REVISED JAN 2000 REMITTANCE REPORT

1 Signature over Printed Name Signature over Printed Name

PHILHEALTH NO. 00 - 000000000-0
EMPLOYER TIN 000-000-000-000
005-409-826 `
2 3 EMPLOYER TYPE 4 TYPE OF REPORT 5 TYPE OF REPORT
COMPLETE EMPLOYER NAME: TAMPILISAN click
LOCALhereGOV'T. UNIT
Regular x
X Regular RF-1 x Quarter Ending Mar. 2014
2001
EMPLOYER SSS NO.
POB. TAMPILISAN, ZAMBOANGA DEL NORTE Quarter
Quarter Ending
Ending Jun.
Jun. 2001
2014
COMPLETE MAILING ADDRESS: Click Here
Private
00-0000000-0 Additional to Previous RF-1
TELEPHONE NO.: X Government Quarter Ending Sept. 2014
2001
Click here Click here EMPLOYERS GSIS POLICY NO.
Deduction to previous RF-1 Quarter Ending Dec. 2014
2001
Household 000000000000
6 7 8 Monthly 9 10
Compensation NHIP PREMIUM CONTRIBUTIONS REMARKS
NAME OF EMPLOYEE/S PhilHealth ID No./ Bracket S-Separated, NE-No Ernings, NH-New Hired

SSS ID No./ 1st 2nd 3rd 1st Month 2nd Month 3nd Month 1st 2nd 3rd DATE OF
SURNAME GIVEN NAME MI GSIS Policy No. Month Month Month PS ES PS ES PS ES Month Month Month EFFECTIVITY
1 CARLOTO ANGELES II R 19-000476979-5 29 #N/A #N/A 437.50 437.50 #N/A #N/A
2 CABARRUBIAS LEO ANGELO L 29 #N/A #N/A 437.50 437.50 #N/A #N/A
3 PAHAYAHAY BENJAMIN H 29 #N/A #N/A 437.50 437.50 #N/A #N/A
4 ALBINO PETROS F 29 #N/A #N/A 437.50 437.50 #N/A #N/A
5 AMPIL WILSON P 29 #N/A #N/A 437.50 437.50 #N/A #N/A
6 CARLOTO NORABETH T 12 #N/A #N/A 225.00 225.00 #N/A #N/A
7 SARMIENTO SHIELA M 14-025065174-7 7 #N/A #N/A 162.50 162.50 #N/A #N/A
8 VILLACURA ROGELIO S 3 #N/A #N/A 112.50 112.50 #N/A #N/A
9 JAMITO JEFFREY 1 #N/A #N/A 87.50 87.50 #N/A #N/A
10 LARATO JAIME R 14-200336380-4 1 #N/A #N/A 87.50 87.50 #N/A #N/A
11 GEGREMOSA VICTORY R 1 #N/A #N/A 87.50 87.50 #N/A #N/A
13 BULAC ISIDRO A 19-026555773-6 1 #N/A #N/A 87.50 87.50 #N/A #N/A
14 PERATER JOVITO L 1 #N/A #N/A 87.50 87.50 #N/A #N/A
ME-5 SUMMARY OF CONTRIBUTION PAYMENTS 12 SUBTOTAL #N/A #N/A 3,125.00 3,125.00 #N/A #N/A
MONTH/ TOTAL ME-5 RECON- DATE # OF (To be Filled on every pages) (PS + ES) 13 CERTIFIED CORRECT:
QUARTER CONTRIBUTION CILIATION NO. PAID EMP. #N/A 6,250.00 #N/A SHERRY LOU P. DAPROSA
1ST MONTH #N/A 15 GRAND TOTAL #N/A #N/A 3,125.00 3,125.00 #N/A #N/A SIGNATURE OVER PRINTED NAME:

2ND MONTH 6,250.00 15 ( To be Filled of this Mun. Accountant

3RD MONTH #N/A 15 is this last page ) (PS + ES) #N/A 6,250.00 #N/A OFFICIAL DESIGNATION:

DATE:
PLEASE READ INSTRUCTION AT THE BACK FOR EACH NUMBERED BOX BEFORE FILLING UP 14 PAGE 1
NOT FOR SALE-CAN BE REPRODUCED
TABLE OF MONTHLY SALARY RANGE
Months Bracket Shares Salary Base
0 - -
1 87.50 7,000.00
2 100.00 8,000.00
3 112.50 9,000.00
4 125.00 10,000.00
5 137.50 11,000.00
6 150.00 12,000.00
7 162.50 13,000.00
8 175.00 14,000.00
9 187.50 15,000.00
10 200.00 16,000.00
1 mon. 11 212.50 17,000.00
2 mon. 12 225.00 18,000.00
3 mon. 13 237.50 19,000.00
14 250.00 20,000.00
15 262.50 21,000.00
16 275.00 22,000.00
17 287.50 23,000.00
18 300.00 24,000.00
20 325.00 26,000.00
21 337.50 27,000.00
22 350.00 28,000.00
23 362.50 29,000.00
24 375.00 30,000.00
25 387.50 31,000.00
26 400.00 32,000.00
28 425.00 34,000.00
29 437.50 35,000.00
TABLE OF MONTHLY SALARY RANGE
Months Bracket Shares Salary Base
0 - -
1 50.00 4,000.00
2 62.50 5,000.00
3 75.00 6,000.00
4 87.50 7,000.00
5 100.00 8,000.00
6 112.50 9,000.00
7 125.00 10,000.00
8 137.50 11,000.00
9 150.00 12,000.00
10 162.50 13,000.00
1 mon. 11 175.00 14,000.00
2 mon. 12 187.50 15,000.00
3 mon. 13 200.00 16,000.00
14 212.50 17,000.00
15 225.00 18,000.00
16 237.50 19,000.00
17 250.00 20,000.00
18 262.50 21,000.00
19 275.00 22,000.00
20 287.50 23,000.00
21 300.00 24,000.00
22 312.50 25,000.00
24 337.50 27,000.00
25 350.00 28,000.00
26 362.50 29,000.00
27 375.00 30,000.00