Maxicare Healthcare Corporation

Maxicare Tower 203 Salcedo Street Brgy. San Lorenzo

Legaspi Village Makati City 1229
VAT REG. TIN 000-487-637-00000

BILLING STATEMENT
Statement Date: June 20, 2024 PAYMENT DUE DATES

JORDAN MITCHELL CRUZ Statement Number 1001552649

Teacher
Payment Reference Number 10015526493
9700749019 - JORDAN MITCHELLCRUZ Total Amount Due on July 20,
953 Concepcion Aguila Street Brgy. 387 Quiapo Manila 1001 2024 PHP 61,398.03
BUS. STYLE: Apolinario Mabini Elementary School (DEPED-Manila)
AGENT/BROKERS NAME: GONZALES, MARIVIC SUERTE FELIPE Mode of Payment Annual
Coverage Period

Please remit to Maxicare Healthcare Corporation the amount of ***SIXTY-ONE THOUSAND THREE HUNDRED NINETY-EIGHT AND 3/100 PESOS ONLY***
(PHP 61,398.03) in payment of the following:

BILLING STATEMENT
Billing Period Covering:
Accounting Document Transaction Type Amount
8100490956 Initial Enrollment 61,398.03
VAT Sales 54,819.67
VAT Exempt Sales -
Zero Rated Sales -
Non-VAT -
VAT Amount 6,578.36
Total Sales 61,398.03
Total Amount Due for Non withholding Tax Agent PHP 61,398.03
Less: Withholding Tax, if Withholding Agent (ATC Code: ) -
TOTAL AMOUNT DUE For Withholding Tax Agent PHP 61,398.03

Please settle your account on or before July 20, 2024 to ensure continuity of coverage. Further, please notify us immediately of any billing error in the Billing
Statement (BS). If no error is reported within fifteen calendar (15) days from Statement Date, the Billing Statement shall be considered final and accurate.

Important Reminders:
1. Any transactions made after the generation of this Billing Statement will be reflected in your subsequent billing statements.
2. To all withholding agents: Submit corresponding certificate of tax withheld (BIR Form No. 2307) to Maxicare upon remittance of payment. Failure to provide CWT
Certificate, the amount will form part of your Outstanding Balance.
3. If your due date falls on a weekend or holiday, please settle on the last working day before due date.
4. Please inform us on any changes on your billing address and/or contact number.
5. Penalty and/or suspension may be charged/implemented in case of delayed or non-payment.
6. Accredited Collection Partners: Equicom Savings Bank (EqB), BPI, Metrobank, PNB, Security Bank, Unionbank, RCBC or BDO (through Bills Payment Facility); CIS
Bayad Center. Payment through our collection partners shall be credited within 3 working days from actual remittance.
*For Suggestions or other inquiries, you can send an email to customerservice@maxicare.com.ph

Accreditation No.:
Date of Accreditation:
Permit To Use (PTU) No.: 1812_0126_PTU_CAS_000418
Date Issued: DECEMBER 28, 2018
Form No.: 1000000001 - 1999999999

THIS DOCUMENT IS NOT VALID FOR CLAIM OF INPUT TAX.

THIS BILLING STATEMENT IS A SYSTEM GENERATED FORM.

SIGNATURE IS NOT REQUIRED.

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(KINDLY SURRENDER THIS PORTION TO THE CASHIER DURING PAYMENT)
JORDAN MITCHELL CRUZ
Teacher COVERED PERIOD
9700749019 - JORDAN MITCHELLCRUZ
953 Concepcion Aguila Street Brgy. 387 Quiapo Manila 1001

( ) Check Bank: _____________ Check No.: _________ DUE DATE

( ) Credit Card Number: ____________________________________ July 20, 2024

( ) Cash

Amount Paid: _______________________