Republika ng Pilipinas

Kagawaran ng Edukasyon
Rehiyon XI
SANGAY NG DAVAO DEL SUR
Munisipalidad ng Padada

DPSU FORM 113

DATE: _________________________

PAYMENT REQUEST FOR MATERNITY LEAVE BENEFITS

DIVISION NAME/CODE: _________________________________________

STATION NAME: _________________________________________
(School for Secondary/District for Elementary)
STATION CODE: (3 Digits) _________________________________________
EMPLOYEE NUMBER: _________________________________________
EMPLOYEE NAME: _________________________________________
SIGNATURE: _________________________________________

PLEASE ATTACH THE FOLLOWING PAPERS:

1. Medical Certificate/CS Form 41 (Original)

2. Duly accomplished and approved Form 6 (Original copy)
3. Marriage Contract for married claimant (Photocopy)
4. Duly accomplished and approved Reinstatement Form (Original Copy)
5. Special Order for Reinstatement (Original Copy)
6. School, District & Division Clearances
7. CS Form 86
8. Birth Certificate of child (Photocopy, for M/L 105 days only)

Position: _________________________ Salary Grade: _________________

Step Increment: ___________________ Basic Salary: _________________
Inclusive period of leave: __________________________________________
Please check appropriate box:

 M/L incurred during Christmas Vacation

 M/L incurred during Summer Vacation

__________________________________
Public Schools District Supervisor
(Name over signature)

Note: Claimant must have applied for Notice of Change (PSU Form 102) prior to this request (for married
claimants).