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Membership Savings Remittance Form (MSRF) : HQP-PFF-053
Membership Savings Remittance Form (MSRF) : HQP-PFF-053
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.
DIGNA G. SANTIAGO
___________________________________________________ ADMIN OFFICER
__________________________________ 11/15/19
_________________________
HEAD OF OFFICE OR AUTHORIZED REPRESENTATIVE DESIGNATION/POSITION DATE
(Signature Over Printed Name)
14 Indicate the total amount due and employer contributions per page.