PHILHEALTH PREMIUM PAYMENT SLIP PHILHEALTH PREMIUM PAYMENT SLIP

PIN/PEN/POGN: 1 4 2 9 1 5 1 0 0 0 1 0 PIN/PEN/POGN: 1 4 2 9 1 5 1 0 0 0 1 0

BUSINESS/AGENCY NAME: Department of Education - Region 02 BUSINESS/AGENCY NAME: Department of Education - Region 02

MEMBER'S NAME: MEMBER'S NAME:

(LAST NAME) (GIVEN NAME) (MIDDLE NAME) (LAST NAME) (GIVEN NAME) (MIDDLE NAME)

CELLPHONE/MOBILE NO.: (078)652-4026 CELLPHONE/MOBILE NO.: (078)652-4026

MEMBER TYPE: MEMBER TYPE:
Voluntary OFW Private x Government Voluntary OFW Private x Government

APPLICABLE PERIOD: 2 0 1 8 APPLICABLE PERIOD: 2 0 1 8

YEAR: YEAR:
1st Quarter 3rd Quarter 1st Quarter 3rd Quarter
(Jan-Mar) (Jul-Sept) Check if applicable: (Jan-Mar) (Jul-Sept) Check if applicable:
w/ sufficient Regularity w/ sufficient Regularity
2nd Quarter 4th Quarter 2nd Quarter 4th Quarter
(Apr-Jun) (Oct-Dec) Arrears / Underpayment (Apr-Jun) (Oct-Dec) Arrears / Underpayment
Others Others
OTHERS: APRIL 2018 Check Payment: OTHERS: MAY 2018 Check Payment:
Bank: __________________ Bank: __________________

AMOUNT PAID: ₱666.16 No.: ____________________

AMOUNT PAID: ₱554.92 No.: ____________________
Date: ___________________ Date: ___________________

PHILHEALTH PREMIUM PAYMENT SLIP PHILHEALTH PREMIUM PAYMENT SLIP

PIN/PEN/POGN: 1 4 2 9 1 5 1 0 0 0 1 0 PIN/PEN/POGN: 1 4 2 9 1 5 1 0 0 0 1 0

BUSINESS/AGENCY NAME: Department of Education - Region 02 BUSINESS/AGENCY NAME: Department of Education - Region 02

MEMBER'S NAME: MEMBER'S NAME:

(LAST NAME) (GIVEN NAME) (MIDDLE NAME) (LAST NAME) (GIVEN NAME) (MIDDLE NAME)

CELLPHONE/MOBILE NO.: (078)652-4026 CELLPHONE/MOBILE NO.: (078)652-4026

MEMBER TYPE: MEMBER TYPE:
Voluntary OFW Private x Government Voluntary OFW Private x Government

APPLICABLE PERIOD: 2 0 1 8 APPLICABLE PERIOD: 2 0 1 8

YEAR: YEAR:
1 Quarter
st
3 Quarter
rd
1 Quarter
st
3 Quarter
rd

(Jan-Mar) (Jul-Sept) Check if applicable: (Jan-Mar) (Jul-Sept) Check if applicable:

w/ sufficient Regularity w/ sufficient Regularity
2nd Quarter 4th Quarter 2nd Quarter 4th Quarter
(Apr-Jun) (Oct-Dec) Arrears / Underpayment (Apr-Jun) (Oct-Dec) Arrears / Underpayment
 Others Others
OTHERS: Check Payment: OTHERS: JUNE 2018 Check Payment:
Bank: __________________ Bank: __________________

AMOUNT PAID:
No.: ____________________
AMOUNT PAID: ₱12,832.40 No.: ____________________
Date: ___________________ Date: ___________________