Stoppage-Deduction Form

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Date: The Chief Regional Payroll Services Unit Budget and Finance Division Dep Ed NCR Dear Sir:

November 28, 2012

I hereby authorized your good office to please STOP / DEDUCT the following effective as indicated hereunder: S T O P
CODE 142A 142A 1068 DESCRIPTION POLICY NO.
EFFECTIVITY DATE TERMINATION DATE

AMOUNT 300.00 300.00 8.783.33

FORTUNE LIFE INS. CO. AUG. 2012 NOV. 2027 FORTUNE LIFE INS. CO. SEPT. 2012 NOV. 2027 PR BANK FEB. 2011 DEC. 2013 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

DEDUCT
CODE 1068 DESCRIPTION POLICY NO.
EFFECTIVITY DATE TERMINATION DATE

AMOUNT 8,781.39

PR BANK NOV. 2012 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

JAN. 2017

Attached herewith is my payslip/supporting document (s). Hoping for your favorable action.

Very Truly Yours, PRINTED NAME WITH SIGNATURE: DIVISION/STATION: EMPLOYEE NO.: MA. CECILIA J. CELESTINO 228 / 022 5314348

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