Republic of the Philippines

RF-1 PHILIPPINE HEALTH INSURANCE CORPORATION EMPLOYER'S REMITTANCE REPORT

Healthline:441-7442 Site: www.philhealth.gov.ph
THIS
Revised
January
2012
Date Received: _____
1
PHILHEALTH NO. 200175302048
By:_______________
EMPLOYER TIN 004557210 Signature Over Printe
2 COMPLETE EMPLOYER NAME 4E BUILDERS CORPORATION 3 EMPLOYER TYPE

/ PRIVATE
COMPLETE MAILING ADDRESS LOT 35 VILLA ANGELICA SUBD. CAMARIN CALOOCAN CITY GOVERNMENT
HOUSEHOLD
TELEPHONE NO. 9621668/9621567/9617947 EMAIL ADDRESS:Four_ebc@yahoo.com.ph
Fill-out this porti
6 PHILHEALTH 7 EMPLOYEE/S INFORMATION 8 declared employee
yet been issued h
IDENTIFICATION NUMBER
(PIN) NAME DATE OF BIRTH
LAST NAME FIRST NAME MIDDLE NAME (mm-dd-yyyy)
SUFFIX

1. 1 9 0 5 2 3 3 1 6 4 3 9 ADOLFO EDUARDO AMANO

2. 1 9 0 5 2 3 3 1 6 4 6 3 CABANG JOSELITO V

3. 1 9 0 5 2 3 3 1 6 4 7 1 CAPUZ REX L

4. 1 9 0 5 2 3 3 1 6 4 9 8 CAUD MILANDO LIWANGEN

5. 0 3 6 3 3 5 1 7 0 DE GUZMAN ARTURO L

6. 1 9 0 5 2 3 3 1 6 5 2 8 DE VERA CESAR J

7. 1 9 0 5 2 3 3 1 6 5 3 6 DOMDOM JR FELIPE ESTIPONA

8. 1 9 0 5 2 3 3 1 6 5 4 4 DOROJA DANNY BOY CENTINO

9. 1 9 0 5 2 3 3 1 6 5 6 0 ECRAELA CARLOS MARTINEZ

10. 1 9 0 5 2 3 3 1 6 5 7 9 ECRAELA EDUARDO GAOAT

11. 1 9 0 5 2 3 3 1 6 5 8 7 ECRAELA FILOMENO GAOAT

12. 1 9 0 5 2 3 3 1 6 5 9 5 ECRAELA MARCELINO GAOAT

13. 1 9 0 5 2 3 3 1 6 6 0 9 ECRAELA VIRGILIO GAOAT

14. 1 9 0 5 2 3 3 1 6 6 1 7 ECRAELA VIRGINIA ECRAELA

15. 1 9 0 5 2 3 3 1 6 6 2 5 GOMEZ CECILIA ESPINOSA

16. 1 9 0 5 2 3 3 1 6 6 3 3 FAJARDO WILLIAM V

17. 1 9 0 5 2 3 3 1 6 6 4 1 GAELA ROSAURO O

18. 1 9 0 5 2 3 3 1 6 5 5 2 DUBLE DANILO K

19. 1 9 0 5 2 3 3 1 6 7 0 6 GODEZANO RUDY B

20. 1 9 0 5 2 3 3 1 6 7 1 4 GUITTU JR DOMINGO Q

### ###
21. 1 9 0 5 2 3 3 1 6 7 2 2 INTIC SEVERINA RELLON

22. 3 3 4 4 1 7 0 0 7 5 LARGABO JOSEPH S

23. 1 9 0 5 2 3 3 1 6 7 4 9 MADROŇO JESUS ALCANTARA

24. 1 9 0 5 2 3 3 1 6 7 5 7 MOYO EDUARDO B

25. 1 9 0 5 2 3 3 1 6 7 6 5 PABELLANO ALAN TUGADE

26. 1 9 0 5 2 3 3 1 6 7 8 1 PIANO PEPITO D

27. 1 9 0 5 2 3 3 1 6 8 0 3 RECOCO ROGEL GAELA

28. 1 9 0 5 2 3 3 1 6 8 1 1 REGINO APOLINARIO P

29. 1 9 0 5 2 3 3 1 6 8 3 8 REYES RONALD E

30. 1 9 0 5 2 3 3 1 6 8 5 4 SARSAGAT ISABELO BUENAVENTE

31. 1 9 0 5 2 3 3 1 6 8 6 2 SAN JUAN ROBERTO ESPINA

32. 1 9 0 5 2 3 3 1 6 8 7 0 VILLAVER EULOGIO S

33. 1 9 0 9 0 3 1 6 8 6 8 8 ARCEO ARMANDO BALARIDO

34. 1 9 0 5 2 3 3 1 6 4 5 5 CABALLERO LUNAR CENTINO

35. 1 1 0 5 0 1 7 6 8 1 1 1 GANOYO EDMUND

36. 3 3 5 7 8 9 9 9 7 5 PALACIO RONALD V

37. 0 2 0 5 0 0 5 8 0 1 2 8 GAELA ANGELINA OCADO

38. 0 2 0 5 0 0 5 8 0 1 4 4 GAELA NORA TULAGAN

39. 1 9 0 5 2 3 3 1 6 6 6 8 MELO DANTE ALBERTO

40. 1 9 0 5 2 3 3 1 6 8 4 6 ROLDAN JOSE JONATHAN SILVA

12 13 ACKNOWLEDGEMENT RECEIPT (PAR/POR/TRANSACTION REFERENCE NO.) 14

APPLICABLE PERIOD REMITTED AMOUNT ACKNOWLEDGEMENT TRANSACTION DATE NO. OF EMPLOYEES (To be accomplished on every pa
RECEIPT NO.
Indicate Total Number of GRAND TOTAL
employees per page

(To be accomplished on every pa

16
UNDER THE PENALTY OF THE LAW, I HEREBY ATTEST THAT THE ABOVE INFORMATIONS PROVIDED HEREIN ARE TRU

__________________________________________________________ ___________________________________________ ________________________________

Signature over printed name Official Designation

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM
 This form maybe reproduce and is NOT FOR SALE

THIS PORTION TO BE FILLED UP BY PHILHEALTH

Received: ________________________ Action Taken:

___________________________
ture Over Printed Name
5 APPLICABLE
LOYER TYPE 4 REPORT TYPE
PERIOD
RIVATE / REGULAR RF-1
OVERNMENT ADDITION TO PREVIOUS RF-1
OUSEHOLD DEDUCTION TO PREVIOUS RF-1
OCTOBER 1999

NHIP PREMIUM
Fill-out this portion only if 10 CONTRIBUTION 11 EMPLOYEE STATUS
declared employee/s has not 9
yet been issued his/her PIN
S-Separated,NE-No Earnings,NH-
TE OF BIRTH SEX PS ES Newly Hired/ Effectivity Date
mm-dd-yyyy) (M/F)
MONTHLY
SALARY
BRACKET
(MSB)

5 37.50 37.50
4 31.25 31.25
4 31.25 31.25
4 31.25 31.25
5 37.50 37.50
4 31.25 31.25
0 - -
4 31.25 31.25
5 37.50 37.50
5 37.50 37.50
5 37.50 37.50
5 37.50 37.50
5 37.50 37.50
5 37.50 37.50
5 37.50 37.50
5 37.50 37.50
5 37.50 37.50
4 31.25 31.25
4 31.25 31.25
0 - -
5 37.50 37.50
0 - -
0 - -
4 31.25 31.25
4 31.25 31.25
0 - -
5 37.50 37.50
4 31.25 31.25
5 37.50 37.50
 4 31.25 31.25
4 31.25 31.25
4 31.25 31.25
4 31.25 31.25
4 31.25 31.25
4 31.25 31.25
4 31.25 31.25
4 31.25 31.25
4 31.25 31.25
4 31.25 31.25
0 - -
15 PREPARED BY:
SUBTOTAL (PS+ES)
1,150.00 1,150.00
ccomplished on every page)
Signature over Printed Name
2,300.00
GRAND TOTAL (PS+ES) Official Designation

ccomplished on every page)

Date

EREIN ARE TRUE AND CORRECT

_______________________________________

Date
HIS FORM 17 PAGE________ OF_________PAGES