HQP-SLF-017

SHORT-TERM LOAN Pag-IBIG EMPLOYER'S ID NUMBER

REMITTANCE FORM ( STLRF )

EMPLOYER/BUSINESS NAME
DEPARTMENT OF EDUCATION - VEDASTO R. SANTIAGO HIGH SCHOOL
EMPLOYER/BUSINESS ADDRESS PERIOD COVERED
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No Street name
DECEMBER, 2018

Subdivision Barangay Municipality/City Province/State/Country (if abroad) ZIP Code TELEPHONE NUMBER
SALACOT SAN MIGUEL BULACAN 3011
APPLICATION / NAME OF BORROWER
MID No. AGREEMENT No. Last Name First Name Middle Name LOAN TYPE AMOUNT
Ext. (JR,SR,III)

TOTAL FOR THIS PAGE

GRAND TOTAL (if last page)
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.

HEAD OF OFFICE OR AUTHORIZED REPRESENTATIVE DESIGNATION/POSITION DATE

(Signature Over Printed Name)

THIS FORM MAY BE REPRODUCED. NOT FOR SALE (Rev. 00, 02/2013)
QP-SLF-017
UMBER

VERED

MBER, 2018

E NUMBER

EMPLOYER
REMARKS

her

DATE
Rev. 00, 02/2013)