Agency Name: DIVISION OF NORTHERN SAMAR

Agency BP Number: 1000001820

AGENCY REMITTANCE ADVICE

FORM A. List of employees with life and retirement premium remittance but without existing record / Reinstatement

Residential
Middle Address/ Mobile Email Civil
Last Name First Name Suffix Name Zip Code Number Address Gender Status
 Basic Date of Place of Agency BP
Date Place Monthly Assumption Status of Station Number
of Birth of Birth Salary of Duty Position Employment
Agency Name: DIVISION OF NORTHERN SAMAR
Agency BP Number: 1000001820

AGENCY REMITTANCE ADVICE

FORM B. List of transferees ( Transfer In / Transfer Out )

Member BP Agency Name

Number Last Name First Name Suffix Midlle Name From To Date of Transfer Salary Position
BALLETA MADONNA ANDANTE LORENZO S. MENZONELADIO P. BALITE MEMORIAL SCHOOL O 8/3/2016 19,077.00 TEACHER 1
 Status of
Employment
PERMANENT
 Agency Name: DIVISION OF NORTHERN SAMAR
Agency BP Number: 1000001820

AGENCY REMITTANCE ADVICE

FORM C. List of employees with salary adjustments for confirmation as

to correct amount of monthly salary and effectively date to be supplied below

Member BP Status of
Number Last Name First Name Suff MI Salary Effectivity Date Position Employment
Agency Name: DIVISION OF NORTHERN SAMAR
Agency BP Number: 1000001820

AGENCY REMITTANCE ADVICE

FORM D. List of employees with no premium remittance for 2 consecutive months

LWOP
Member BP Effectivity Date
Number Last Name First Name Suffix MI Reason 1 Effectivity Date From To

1 Reason: please specify whether resigned/ retired/ deceased/ dismissed/ end of term/ dropped from the roll/ suspended
2 Updating of LWOP is only limited to present date. Please resend the request for the next succeeding periods until completely updated.
Agency Name: DIVISION OF NORTHERN SAMAR
Agency BP Number: 1000001820

FOR AGENCY REMITTANCE ADVICE

FORM E. List of employees with changes / correction in their Personal Data

Last Name First Name Suffix Middle Name Residential Address/Zip Code Mobile Number Email Address Civil Status Date of Birth *

Member BP Number From To From To From To From To From To From To From To From To From
2002328917 ORIO ORIO JESUS JESUS BUTOD BUTOD PALAPAG N. S PALAPAG N. SAMAR WIDOW WIDOW 12/23/1954

Please attach scanned copy of the original NSO Birth Certificate including the NSO Official Receipt
Member must be in ACTIVE Service upon request.
Date of Birth * Place of Birth Gender

To From To From To
12/23/1954 PALAPAG N. PALAPAG N. SAM FEMALE MALE
 BP NUMBER

SERVICE RECORD
(To Be Accoumplished By Employer)

NAME: (If married women give also full maiden

(Surname) (Given Name) (Middle Name)

BIRTH: (Data herein should be checked from birth

DATE PLACE or baptismal certificate or some other

This is to certify that the employee named hereinabove actually rendered

services in this Office as shown by the service record below, each line of which
is supported by appointment and other papers actually issued by this Office

SERVICE RECORD OF APPOINTMENT OFFICE ENTITY/DIVISION LEAVE SEPARATION

(Inclusive dates) Designation Employment Salary Station/Place BRANCH WITHOUT PAY DATE CAUSE
From To Status of assignment From To

ATTY. ELEANOR C. CALUMPIANO

(Chief or Head of Office)

OIC- Administrative Officer

 (Designation)

1/13/2015
Date
REMARKS
ADDITIONAL DEPENDENT FORM FOR CM POLICY ONLY

Agency Name: DIVISION OF NORTHERN SAMAR

Agency BP Number: 1000001820

Name of Agency BP Number Name of Member Name of Beneficiaries

Relationship Date of Birth