PSU FORM 111

REQUEST FOR DELETION OF DEDUCTION

DIVISION NAME/CODE:

STATION NAME:
(School for Secondary/Distict for Elementary)

STATION CODE: (3 Digits)

EMPLOYEE NUMBER:

COMPLETE NAME:

EMPLOYEES SIGNATURE:

NAME OF DEDUCTION

DEDUCTION CODE

AMOUNT OF DEDUCTION

POLICY NUMBER

DATE DEDUCTION STARTED

(In the Payroll)
REASON FOR DELETION

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)