2010-ESCF01-01

ESC Form 1-Billing Statement (ESC-Returnees)

For All Regions Except NCR

This Billing Statement also serves as the contract between DepED and the private school with regard to the latter's
participation in the ESC program of the GASTPE in accordance with the program guidelines issued for the school
year stated above.

Instructions: Please prepare 4 copies of this form and no erasures.

Billed to: Department of Education Date:

Address: Pasig City

School Id:
School Name:
School Address:
On account of: ESC Grants for School Year 2010-2011

Total Grantees & Amount Due for ESC School Year 2010-2011 (ESC-Returnees)

Year Level No. of Amount of Grant Total Amount Due by Year

Grantees Level
First Year 5,000.00
Second Year 5,000.00
Third Year 5,000.00
Fourth Year 5,000.00
Total Grantees Total Amount Due

We certify, under the penalties of perjury, that the data entered above are consistent with the list of qualified ESC-Returnees listed in
ESC Form 2.

Parents' Association President/Representative Faculty Association President/Representative

School Head

Note: Signature over printed name.

Special Instructions:

Please deposit payments to school's account with Land Bank of the Philippines (LBP). The account details of which are as follows:

Branch:

School Account Name:

Account number:

Requirement: Please attach an IMI1 or STI1 printout.

Recommending approval for payment amounting to Php_______________________________

Ms. Carolina C. Porio

FAPE Executive Director
 ESC Form 2-List of Grantees for SY 2010-2011 (ESC-Returnees)
School ID Name of School 2010-ESCF02-01
Page of
Region Province Municipality Street/Barangay No. of grantees for this page

Instructions: Please prepare 4 copies. Type the data needed. The students' names shall be alphabetically arranged (Last Name first and then First Name) regardless of gender, year level, or class section. No erasures allowed.
No. Last Name First Name MI Gender Current Year Level Last School Year Attended Reason for Dropping/Leaving School No.

We certify, under the penalties of perjury, that the list of students entered above are the qualified ESC-Returneesfor School Year 2010-2011 in accordance with the ESC Implementing Guidelines and have attended classes until
July 15, 2010.

Parents' Association President/Representative Faculty Association President/Representative School Head

Note: Signature over printed name.

 2010-ESCF03-01

ESC Form 3-Certification of Tuition and Other School Fees

For School Year 2010-2011
School Id:
School Name:
School Address:

First Year Second Year Third Year Fourth Year

I. Tuition Fee P P P P

II. Other Standard School Fees

(Please indicate breakdown)

Total Other Standard School Fees P P P P

III. Other Non-standard School Fees

(Please indicate breakdown)

Total Other Non-standard School Fees P P P P

IV. Total Tuition and Other School Fees (Sum of Part I, Part II, and Part III)

P P P P

V. Please indicate any special concessions given to ESC grantees (e.g. tuition waiver, discounts, any forms of assistance, etc.)
 P P P P

We certify, under the penalties of perjury, that the above information contained herein is true and correct and is in accordance with the ESC Implementing
Guidelines.

Faculty Association President/Representative Parents' Association President/Representative

School Head
Note: Signature over printed name.
Please attach a true copy of the current school year's schedule of tuition and other school fees submitted and marked received by the DepEd
Regional/Division Office.
 ESC Form 4-List of Licensed Teachers (LET-Passers)
School ID Name of School 2010-ESCF04-01
Page of
Region Province Municipality Street/Barangay No. of grantees for this page

Instructions: Please prepare 4 copies. Type the data needed. Teachers' names shall be alphabetically arranged (Last Name first and then First Name) regardless of their gender. No erasures allowed.
No. Last Name First Name MI Gender License Number Date Issued No. of Teaching Loads Classes Handled Monthly Salary No.

We certify, under the penalties of perjury, that the list above are teachers who have passed the Professional Regulatory Commission exam for teachers.

Parents' Association President/Representative Faculty Association President/Representative School Head

Note: Signature over printed name.