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HQP-SLF-017

SHORT-TERM LOAN Pag-IBIG EMPLOYER'S ID NUMBER

REMITTANCE FORM ( STLRF ) 207743030008


EMPLOYER/BUSINESS NAME
TANGLAW-TOUCH CARE FOUNDATION INC.
EMPLOYER/BUSINESS ADDRESS PERIOD COVERED
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No Street name
#22 PRES. ML QUEZON ST.
Subdivision Barangay Municipality/City Province/State/Country (if abroad) ZIP Code TELEPHONE NUMBER

APPLICATION / NAME OF BORROWER EMPLOYER


MID No. Last Name First Name Middle Name
AGREEMENT No. Ext. (JR,SR,III) LOAN TYPE AMOUNT REMARKS

TOTAL FOR THIS PAGE


GRAND TOTAL (if last page)
EMPLOYER CERTIFICATION
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.

HEAD OF OFFICE OR AUTHORIZED REPRESENTATIVE DESIGNATION/POSITION DATE


(Signature Over Printed Name)

THIS FORM MAY BE REPRODUCED. NOT FOR SALE (Rev. 00, 02/2013)

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