EMP NAME

ADDRESS
PEN
TEL #
INCHARGE
POSITION
# OF EE'S

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45

LAST NAME

SUFFIX

EMPLOYER TYPE
YEAR
MONTH
TYPE OF REPORT
FIRST NAME

46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97

98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149

150

EMPLOYEE COUNT 0

SSS NUMBER

PRIVATE
2011
7
R
MIDDLE NAME

TIN
ALLOTED GS
PHILHEALTH NO

TOTAL PS
TOTAL ES
NO ALLOTED GS
TOTAL ARREARS
TOTAL PS & TOTAL ES
TOTAL PS + NO ALLOTED
SB
SALARY
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0.00
0.00
0.00
0.00
0.00
0.00
PS
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00

0.00
0.00
0.00
0.00
0.00
0.00
ES
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

#
1
ME-5 #
AMOUNT
DATE
JULY
MONTH
PAYMENT
0.00
REMARKS
ALLOTED
DATE
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

SP

7/1/2011

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00

0.00

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
marc punzalan

REGULAR

00-0000000-0

GOVERNMENT

NAME OF EMPLOYEE/S

MONTHLY
SALARY
BRACKET

PhilHealth ID No.

GIVEN NAME

MI

DEDUCTION TO PREVIOUS RF-1

AUG

SEP

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

PS

SEP
ES

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

PS

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

ADDITION TO PREVIOUS RF-1

0000000000
9

JUL

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

TYPE OF REPORT
REGULAR RF-1

EMPLOYER'S SSS NO.

PRIVATE

MAILING ADDRESS

SURNAME

Signature Over Printed Name

EMPLOYER TYPE

TELEPHONE #

Action Taken:

By:

Signature Over Printed Name

EMPLOYER NAME

Date Screened:

By:

QUARTER ENDING JUN

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

ES

JULY

DATE OF
EFFECTIVITY

| 14 | PAGE 13 OF 48 PAGES

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
marc punzalan

REGULAR

00-0000000-0

GOVERNMENT

NAME OF EMPLOYEE/S

MONTHLY
SALARY
BRACKET

PhilHealth ID No.

GIVEN NAME

MI

DEDUCTION TO PREVIOUS RF-1

AUG

SEP

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

PS

SEP
ES

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

PS

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

ADDITION TO PREVIOUS RF-1

0000000000
9

JUL

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

TYPE OF REPORT
REGULAR RF-1

EMPLOYER'S SSS NO.

PRIVATE

MAILING ADDRESS

SURNAME

Signature Over Printed Name

EMPLOYER TYPE

TELEPHONE #

Action Taken:

By:

Signature Over Printed Name

EMPLOYER NAME

Date Screened:

By:

QUARTER ENDING JUN

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

ES

JULY

DATE OF
EFFECTIVITY

| 14 | PAGE 14 OF 48 PAGES

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
marc punzalan

REGULAR

00-0000000-0

GOVERNMENT

NAME OF EMPLOYEE/S

MONTHLY
SALARY
BRACKET

PhilHealth ID No.

GIVEN NAME

MI

DEDUCTION TO PREVIOUS RF-1

AUG

SEP

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

PS

SEP
ES

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

PS

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

ADDITION TO PREVIOUS RF-1

0000000000
9

JUL

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

TYPE OF REPORT
REGULAR RF-1

EMPLOYER'S SSS NO.

PRIVATE

MAILING ADDRESS

SURNAME

Signature Over Printed Name

EMPLOYER TYPE

TELEPHONE #

Action Taken:

By:

Signature Over Printed Name

EMPLOYER NAME

Date Screened:

By:

QUARTER ENDING JUN

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

ES

JULY

DATE OF
EFFECTIVITY

SP

07/01/11

| 14 | PAGE 15 OF 48 PAGES

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
marc punzalan

REGULAR

00-0000000-0

GOVERNMENT

NAME OF EMPLOYEE/S

MONTHLY
SALARY
BRACKET

PhilHealth ID No.

GIVEN NAME

MI

DEDUCTION TO PREVIOUS RF-1

AUG

SEP

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

PS

SEP
ES

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

PS

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

ADDITION TO PREVIOUS RF-1

0000000000
9

JUL

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

TYPE OF REPORT
REGULAR RF-1

EMPLOYER'S SSS NO.

PRIVATE

MAILING ADDRESS

SURNAME

Signature Over Printed Name

EMPLOYER TYPE

TELEPHONE #

Action Taken:

By:

Signature Over Printed Name

EMPLOYER NAME

Date Screened:

By:

QUARTER ENDING JUN

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

ES

JULY

DATE OF
EFFECTIVITY

| 14 | PAGE 16 OF 48 PAGES

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
marc punzalan

REGULAR

00-0000000-0

GOVERNMENT

NAME OF EMPLOYEE/S

MONTHLY
SALARY
BRACKET

PhilHealth ID No.

GIVEN NAME

MI

DEDUCTION TO PREVIOUS RF-1

AUG

SEP

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

PS

SEP
ES

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

PS

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

ADDITION TO PREVIOUS RF-1

0000000000
9

JUL

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

TYPE OF REPORT
REGULAR RF-1

EMPLOYER'S SSS NO.

PRIVATE

MAILING ADDRESS

SURNAME

Signature Over Printed Name

EMPLOYER TYPE

TELEPHONE #

Action Taken:

By:

Signature Over Printed Name

EMPLOYER NAME

Date Screened:

By:

QUARTER ENDING JUN

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

ES

JULY

DATE OF
EFFECTIVITY

| 14 | PAGE 17 OF 48 PAGES

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

NAME OF EMPLOYEE/S

MONTHLY
SALARY
BRACKET

PhilHealth ID No.

GIVEN NAME

MI

128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150

DEDUCTION TO PREVIOUS RF-1

AUG

SEP

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

PS

SEP
ES

PS

QUARTER ENDING JUN

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

JULY

ES

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

12

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

ADDITION TO PREVIOUS RF-1

0000000000
9

JUL

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

127

11

00-0000000-0

GOVERNMENT

TYPE OF REPORT
REGULAR RF-1

EMPLOYER'S SSS NO.

PRIVATE

126

marc punzalan

REGULAR

MAILING ADDRESS

SURNAME

Signature Over Printed Name

EMPLOYER TYPE

TELEPHONE #

Action Taken:

By:

Signature Over Printed Name

EMPLOYER NAME

Date Screened:

By:

13

DATE OF
EFFECTIVITY

| 14 | PAGE 18 OF 48 PAGES

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

Signature Over Printed Name

3

EMPLOYER TYPE

1st Month
2nd Month
3rd Month

marc punzalan

PhilHealth ID No.

GIVEN NAME

MI
ME - 5 SUMMARY OF CONTRIBUTIONS PAYMENTS 12

MONTH /
QUARTER

TOTAL
CONTRIBUTION

ME-5
RECONCILIATION

DATE PAID

NO. OF
EMPLOYEES

0
0
0

JUL

SUBTOTAL

MONTHLY
SALARY
BRACKET
AUG

SEP

(PS + ES)

(To be accomplished on every page)

GRAND
TOTAL

(PS + ES)

(To be accomplished on the last page)

ADDITION TO PREVIOUS RF-1

DEDUCTION TO PREVIOUS RF-1

0000000000
9

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

0.00
0.00
0.00
0.00

0.00
0.00

PS

SEP
ES

0.00
0.00
0.00

0.00
0.00

0.00

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

TYPE OF REPORT
REGULAR RF-1

00-0000000-0

GOVERNMENT

NAME OF EMPLOYEE/S

11

4
EMPLOYER'S SSS NO.

PRIVATE

MAILING ADDRESS

SURNAME

Signature Over Printed Name

REGULAR

TELEPHONE #

Action Taken:

By:

EMPLOYER NAME

Date Screened:

By:

PS

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

ES

0.00
0.00
0.00

QUARTER ENDING JUN

0.00 13
0.00

DATE OF
EFFECTIVITY

JULY

CERTIFIED CORRECT:
SIGNATURE OVER PRINTED NAME

0.00
DATE

| 14 | PAGE 19 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 20 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 21 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

07/01/11

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 22 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 23 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 24 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 25 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

CERTIFIED CORRECT:
SIGNATURE OVER PRINTED NAME

DATE

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 26 OF 48 PAGES

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Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
marc punzalan

REGULAR

00-0000000-0

GOVERNMENT

NAME OF EMPLOYEE/S

MONTHLY
SALARY
BRACKET

PhilHealth ID No.

GIVEN NAME

MI

DEDUCTION TO PREVIOUS RF-1

AUG

SEP

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

PS

SEP
ES

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

PS

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

ADDITION TO PREVIOUS RF-1

0000000000
9

JUL

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

TYPE OF REPORT
REGULAR RF-1

EMPLOYER'S SSS NO.

PRIVATE

MAILING ADDRESS

SURNAME

Signature Over Printed Name

EMPLOYER TYPE

TELEPHONE #

Action Taken:

By:

Signature Over Printed Name

EMPLOYER NAME

Date Screened:

By:

QUARTER ENDING JUN

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

ES

JULY

DATE OF
EFFECTIVITY

| 14 | PAGE 31 OF 48 PAGES

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
marc punzalan

REGULAR

00-0000000-0

GOVERNMENT

NAME OF EMPLOYEE/S

MONTHLY
SALARY
BRACKET

PhilHealth ID No.

GIVEN NAME

MI

DEDUCTION TO PREVIOUS RF-1

AUG

SEP

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

PS

SEP
ES

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

PS

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

ADDITION TO PREVIOUS RF-1

0000000000
9

JUL

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

TYPE OF REPORT
REGULAR RF-1

EMPLOYER'S SSS NO.

PRIVATE

MAILING ADDRESS

SURNAME

Signature Over Printed Name

EMPLOYER TYPE

TELEPHONE #

Action Taken:

By:

Signature Over Printed Name

EMPLOYER NAME

Date Screened:

By:

QUARTER ENDING JUN

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

ES

JULY

DATE OF
EFFECTIVITY

| 14 | PAGE 32 OF 48 PAGES

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
marc punzalan

REGULAR

00-0000000-0

GOVERNMENT

NAME OF EMPLOYEE/S

MONTHLY
SALARY
BRACKET

PhilHealth ID No.

GIVEN NAME

MI

DEDUCTION TO PREVIOUS RF-1

AUG

SEP

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

PS

SEP
ES

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

PS

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

ADDITION TO PREVIOUS RF-1

0000000000
9

JUL

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

TYPE OF REPORT
REGULAR RF-1

EMPLOYER'S SSS NO.

PRIVATE

MAILING ADDRESS

SURNAME

Signature Over Printed Name

EMPLOYER TYPE

TELEPHONE #

Action Taken:

By:

Signature Over Printed Name

EMPLOYER NAME

Date Screened:

By:

QUARTER ENDING JUN

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

ES

JULY

DATE OF
EFFECTIVITY

SP

07/01/11

| 14 | PAGE 33 OF 48 PAGES

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
marc punzalan

REGULAR

00-0000000-0

GOVERNMENT

NAME OF EMPLOYEE/S

MONTHLY
SALARY
BRACKET

PhilHealth ID No.

GIVEN NAME

MI

DEDUCTION TO PREVIOUS RF-1

AUG

SEP

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

PS

SEP
ES

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

PS

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

ADDITION TO PREVIOUS RF-1

0000000000
9

JUL

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

TYPE OF REPORT
REGULAR RF-1

EMPLOYER'S SSS NO.

PRIVATE

MAILING ADDRESS

SURNAME

Signature Over Printed Name

EMPLOYER TYPE

TELEPHONE #

Action Taken:

By:

Signature Over Printed Name

EMPLOYER NAME

Date Screened:

By:

QUARTER ENDING JUN

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

ES

JULY

DATE OF
EFFECTIVITY

| 14 | PAGE 34 OF 48 PAGES

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
marc punzalan

REGULAR

00-0000000-0

GOVERNMENT

NAME OF EMPLOYEE/S

MONTHLY
SALARY
BRACKET

PhilHealth ID No.

GIVEN NAME

MI

DEDUCTION TO PREVIOUS RF-1

AUG

SEP

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

PS

SEP
ES

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

PS

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

ADDITION TO PREVIOUS RF-1

0000000000
9

JUL

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

TYPE OF REPORT
REGULAR RF-1

EMPLOYER'S SSS NO.

PRIVATE

MAILING ADDRESS

SURNAME

Signature Over Printed Name

EMPLOYER TYPE

TELEPHONE #

Action Taken:

By:

Signature Over Printed Name

EMPLOYER NAME

Date Screened:

By:

QUARTER ENDING JUN

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

ES

JULY

DATE OF
EFFECTIVITY

| 14 | PAGE 35 OF 48 PAGES

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

NAME OF EMPLOYEE/S

MONTHLY
SALARY
BRACKET

PhilHealth ID No.

GIVEN NAME

MI

128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150

DEDUCTION TO PREVIOUS RF-1

AUG

SEP

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

PS

SEP
ES

PS

QUARTER ENDING JUN

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

JULY

ES

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

12

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

ADDITION TO PREVIOUS RF-1

0000000000
9

JUL

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

127

11

00-0000000-0

GOVERNMENT

TYPE OF REPORT
REGULAR RF-1

EMPLOYER'S SSS NO.

PRIVATE

126

marc punzalan

REGULAR

MAILING ADDRESS

SURNAME

Signature Over Printed Name

EMPLOYER TYPE

TELEPHONE #

Action Taken:

By:

Signature Over Printed Name

EMPLOYER NAME

Date Screened:

By:

13

DATE OF
EFFECTIVITY

| 14 | PAGE 36 OF 48 PAGES

Republic of the Philippines

RF-1
REVISED JAN 2004

1 PHILHEALTH NO.
EMPLOYER TIN

FOR PHILHEALTH USE

PHILIPPINE HEALTH INSURANCE CORPORATION

EMPLOYER'S QUARTERLY
REMITTANCE REPORT

Date Screened:

Action Taken:

00-000000000-0
000-000-000-000

Signature Over Printed Name

3

EMPLOYER TYPE

1st Month
2nd Month
3rd Month

marc punzalan

PhilHealth ID No.

GIVEN NAME

MI
ME - 5 SUMMARY OF CONTRIBUTIONS PAYMENTS 12

MONTH /
QUARTER

TOTAL
CONTRIBUTION

ME-5
RECONCILIATION

DATE PAID

NO. OF
EMPLOYEES

0
0
0

JUL

SUBTOTAL

MONTHLY
SALARY
BRACKET
AUG

SEP

(PS + ES)

(To be accomplished on every page)

GRAND
TOTAL

(PS + ES)

(To be accomplished on the last page)

ADDITION TO PREVIOUS RF-1

DEDUCTION TO PREVIOUS RF-1

0000000000
9

10

NHIP PREMIUM CONTRIBUTIONS

JUL
PS

AUG
ES

0.00
0.00
0.00
0.00

0.00
0.00

PS

SEP
ES

0.00
0.00
0.00

0.00
0.00

0.00

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

APPPLICABLE QUARTER
QUARTER ENDING MAR 2011

HOUSEHOLD EMPLOYER'S SSS / GSIS POLICY NO.

HOUSEHOLD

TYPE OF REPORT
REGULAR RF-1

00-0000000-0

GOVERNMENT

NAME OF EMPLOYEE/S

11

4
EMPLOYER'S SSS NO.

PRIVATE

MAILING ADDRESS

SURNAME

Signature Over Printed Name

REGULAR

TELEPHONE #

Action Taken:

By:

EMPLOYER NAME

Date Screened:

By:

PS

2011

QUARTER ENDING SEP

2011

QUARTER ENDING DEC

2011

REMARKS

S-Separated, NE-No Earnings, NH-Newly Hired

ES

0.00
0.00
0.00

QUARTER ENDING JUN

0.00 13
0.00

DATE OF
EFFECTIVITY

JULY

CERTIFIED CORRECT:
SIGNATURE OVER PRINTED NAME

0.00
DATE

| 14 | PAGE 37 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 38 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 39 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

07/01/11

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 40 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 41 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 42 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 43 OF 48 PAGES

FOR PHILHEALTH USE

Action Taken:

APPPLICABLE QUARTER
2011
2011
2011
2011

REMARKS
DATE OF
EFFECTIVITY

CERTIFIED CORRECT:
SIGNATURE OVER PRINTED NAME

DATE

marc punzalan

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM

| 14 | PAGE 44 OF 48 PAGES

REMITTANCE REPORT

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