V.

MONTA CONSTRUCTION
SERVICES
L4,B38,PH4, SOLDIERS HILL 4,
MOLINO 6, BACOOR CITY, CAVITE

PROJECT: NEW GLORY

PPROJECT ADDRESS: Tanza, Cavite
Last First Middle

NAME:
POSITION: DATE OF EMPLOYMENT
STATUS OF EMPLOYMENT: Project Based
DATE OF BIRTH: CIVIL STATUS

I hereby certify that I was given the opportunity to enroll for the following
mandatory benefits provided by the government and the law

However, I am declining to contribute for the following benefits:

Social Security System (SSS)

Home Development Mutual Fund (Pag-Ibig or HDMF)

Philippine Health Insurance Corporation (Philhealth)

I acknowledge I have been given the opportunity to apply for the coverage of the
above benefits but I decline for the reason of:

By declining the above enumerated benefits, I acknowledge that I and my dependents

(if any) may have to wait until In have enrolled.

Name of Employee