Republic of the Philippines

DEPARTMENT OF EDUCATION
Regional Office IX, Zamboanga Peninsula
Division of Zamboanga del Sur
Provincial Government Center, Dao, Pagadian City
Telefax: (062)-214-1991

PAYMENT REQUEST FOR MATERNITY LEAVE BENEFITS

DIVISION NAME CODE:

STATION NAME:

STATION CODE:

EMPLOYEE NUMBER:
EMPLOYEE NAME:
SIGNATURE:

PLEASE ATTACH THE FOLLOWING PAPERS:

1. MEDICAL CERTIFICATE/CS FORM 41 (1 Original Copy, 1 Authenticated Copy)

2. APPROVED MATERNITY LEAVE (2 Authenticated Copies)
3. BIRTH CERTIFICATE OF CHILD FOR CLAIMS COVERING LONG VACATION BREAK.
(2 Authenticated Copies)
4. LETTER REQUEST FOR MATERNITY DOUBLE PAY CLAIM (2 Original Copies)
5. SO# NUMBER (SERVICE RECORDS SECTION) (2 Authenticated Copies)
6. DISTRICT CLEARANCE for Elementary / SCHOOL CLEARANCE for Secondary (2 Copies)
7. DIVISION CLEARANCE (2 Copies)

POSITION: ________________________________________ SALARY GRADE: __________________

STEP INCREMENT: _________________________________ BASIC SALARY: ___________________

INCLUSIVE PERIOD OF LEAVE: _________________________________________________________

SPECIFY: M/L WITH FULL PAY ________________________

M/L WITH HALF PAY ________________________

___________________________
Principal/District Supervisor
(Name over signature)