Civil Service Form No.

6, revised 2020
UP TO 60 CALENDAR DAYS Annex A

Date of receipt:
1/24/2023
_________________

APPLICATION FOR LEAVE

1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)

SDO LIGAO CITY, AMTIC ELEM. SCHOOL DAYANDANTE BLANCHIE ALANO

3. DATE OF FILING : JANUARY 24, 2023 4. POSITION : TEACHER 1 5. SALARY _P25,439.00__________________

6. DETAILS OF APPLICATION
6.A TYPE OF LEAVE TO BE AVAILED OF 6.B DETAILS OF LEAVE

X Vacation Leave (Sec. 51, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Vacation/Special Privilege Leave:
Mandatory/Forced Leave(Sec. 25, Rule XVI, Omnibus Rules Implementing E.O. No. 292) X Within the Philippines __________________________
Sick Leave (Sec. 43, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Abroad (Specify) _____________________________
Maternity Leave (R.A. No. 11210 / IRR issued by CSC, DOLE and SSS) In case of Sick Leave:
Paternity Leave (R.A. No. 8187 / CSC MC No. 71, s. 1998, as amended) In Hospital (Specify Illness) _____________________
Special Privilege Leave (Sec. 21, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Out Patient (Specify Illness) ____________________
Solo Parent Leave (RA No. 8972 / CSC MC No. 8, s. 2004) _____________________________________________
Study Leave (Sec. 68, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Special Leave Benefits for Women:
10-Day VAWC Leave (RA No. 9262 / CSC MC No. 15, s. 2005) (Specify Illness) ________________________________
Rehabilitation Privilege (Sec. 55, Rule XVI, Omnibus Rules Implementing E.O. No. 292) _____________________________________________
Special Leave Benefits for Women (RA No. 9710 / CSC MC No. 25, s. 2010) In case of Study Leave:
Special Emergency (Calamity) Leave (CSC MC No. 2, s. 2012, as amended) Completion of Master's Degree
Adoption Leave (R.A. No. 8552) BAR/Board Examination Review
Other purpose:
Others: Monetization of Leave Credits
Terminal Leave

6.C NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION

30 DAYS Not Requested
INCLUSIVE DATES Requested
JANUARY 30-FEBRUARY 28, 2023 _____________________________________
(Signature of Applicant)

7. DETAILS OF ACTION ON APPLICATION

7.A CERTIFICATION OF LEAVE CREDITS 7.B RECOMMENDATION
As of _______________________ For approval
Vacation Leave Sick Leave For disapproval due to ________________________
Total Earned ___________________________________________
Less this application ___________________________________________
Balance ___________________________________________

__________________________________________________ ARSUR C. SURUIZ

REBECCA M. ROLDA School Principal I
Administrative Officer IV (Personnel) Division Chief , if Below Division Chief
School Head , if Teachers and Non-Teaching Personnel

7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:

_______ days with pay ________________________________________
_______ days without pay ________________________________________
_______ others (Specify) ________________________________________

MAYLANI L. GALICIA
__________________________________________
Schools Assistant Division Superintendent
Civil Service Form No. 6
revised 2020 Annex A

Date of receipt:

_________________

APPLICATION FOR LEAVE

1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)

SDO LIGAO CITY, AMTIC ELEMENTARY SCHOOL SURUIZ, ARSUR CORNELIO

3. DATE OF FILING : November 2, 2022 4. POSITION : SCHOOL PRINCIPAL I 5. SALARY Php 52,088.00

6. DETAILS OF APPLICATION
6.A TYPE OF LEAVE TO BE AVAILED OF 6.B DETAILS OF LEAVE

Vacation Leave (Sec. 51, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Vacation/Special Privilege Leave:
Mandatory/Forced Leave(Sec. 25, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Within the Philippines __________________________
Sick Leave (Sec. 43, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Abroad (Specify) _____________________________
Maternity Leave (R.A. No. 11210 / IRR issued by CSC, DOLE and SSS) In case of Sick Leave:
Paternity Leave (R.A. No. 8187 / CSC MC No. 71, s. 1998, as amended) In Hospital (Specify Illness) _____________________
X Special Privilege Leave (Sec. 21, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Out Patient (Specify Illness) ____________________
Solo Parent Leave (RA No. 8972 / CSC MC No. 8, s. 2004) _____________________________________________
Study Leave (Sec. 68, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Special Leave Benefits for Women:
10-Day VAWC Leave (RA No. 9262 / CSC MC No. 15, s. 2005) (Specify Illness) ________________________________
Rehabilitation Privilege (Sec. 55, Rule XVI, Omnibus Rules Implementing E.O. No. 292) _____________________________________________
Special Leave Benefits for Women (RA No. 9710 / CSC MC No. 25, s. 2010) In case of Study Leave:
Special Emergency (Calamity) Leave (CSC MC No. 2, s. 2012, as amended) Completion of Master's Degree
Adoption Leave (R.A. No. 8552) BAR/Board Examination Review
Other purpose:
Others: Monetization of Leave Credits
_____________________________________ Terminal Leave

6.C NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION

1 day Not Requested
INCLUSIVE DATES X Requested
November 2, 2022 _____________________________________
(Signature of Applicant)

7. DETAILS OF ACTION ON APPLICATION

7.A CERTIFICATION OF LEAVE CREDITS 7.B RECOMMENDATION
As of _______________________ For approval
Vacation Leave Sick Leave For disapproval due to ________________________
Total Earned ___________________________________________
Less this application ___________________________________________
Balance ___________________________________________

__________________________________________________ MAYLANI L. GALICIA

_______________________________________
REBECCA M. ROLDA Assistant Schools Division Superintendent
Administrative Officer IV (Personnel)
*if Division Chief and School Head

7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:

_______ days with pay ________________________________________
_______ days without pay ________________________________________
_______ others (Specify) ________________________________________

NELSON S. MORALES, JR.

__________________________________________
Schools Division Superintendent
Civil Service Form No. 6, revised 2020
MORE THAN 60 CALENDAR DAYS TO 1 YEAR Annex A

Date of receipt:

_________________

APPLICATION FOR LEAVE

1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)

MACARARANGA IVY TALAVERA

3. DATE OF FILING September 1, 2022 4. POSITION: Teacher III 5. SALARY Php 29, 798.00

6. DETAILS OF APPLICATION
6.A TYPE OF LEAVE TO BE AVAILED OF 6.B DETAILS OF LEAVE

Vacation Leave (Sec. 51, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Vacation/Special Privilege Leave:
Mandatory/Forced Leave(Sec. 25, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Within the Philippines __________________________
Sick Leave (Sec. 43, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Abroad (Specify) _____________________________
/ Maternity Leave (R.A. No. 11210 / IRR issued by CSC, DOLE and SSS) In case of Sick Leave:
Paternity Leave (R.A. No. 8187 / CSC MC No. 71, s. 1998, as amended) In Hospital (Specify Illness) _____________________
Special Privilege Leave (Sec. 21, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Out Patient (Specify Illness) ____________________
Solo Parent Leave (RA No. 8972 / CSC MC No. 8, s. 2004) _____________________________________________
Study Leave (Sec. 68, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Special Leave Benefits for Women:
10-Day VAWC Leave (RA No. 9262 / CSC MC No. 15, s. 2005) (Specify Illness) ________________________________
Rehabilitation Privilege (Sec. 55, Rule XVI, Omnibus Rules Implementing E.O. No. 292) _____________________________________________
Special Leave Benefits for Women (RA No. 9710 / CSC MC No. 25, s. 2010) In case of Study Leave:
Special Emergency (Calamity) Leave (CSC MC No. 2, s. 2012, as amended) Completion of Master's Degree
Adoption Leave (R.A. No. 8552) BAR/Board Examination Review
Other purpose:
Others: Monetization of Leave Credits
_____________________________________ Terminal Leave

6.C NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION

105 days Not Requested
INCLUSIVE DATES Requested
September 5, 2022 - January 2, 2023 _____________________________________
(Signature of Applicant)

7. DETAILS OF ACTION ON APPLICATION

7.A CERTIFICATION OF LEAVE CREDITS 7.B RECOMMENDATION
As of _______________________ For approval
Vacation Leave Sick Leave For disapproval due to ________________________
Total Earned ___________________________________________
Less this application ___________________________________________
Balance ___________________________________________

__________________________________________________ ARSUR C. SURUIZ

REBECCA M. ROLDA School Principal I
Administrative Officer IV (Personnel) ASDS , if Division Chief & School Head
Division Chief & ASDS, if Below Division Chief
School Head & ASDS , if Teachers and Non-Teaching Personnel

7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:

_______ days with pay ________________________________________
_______ days without pay ________________________________________
_______ others (Specify) ________________________________________

NELSON S. MORALES, JR.

__________________________________________
Schools Division Superintendent