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TEACHER/ EMPLOYEE INDIVIDUAL RECORD FORM
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Division:
Antique
Station: ________________________
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Division Code:
004
Station Code: ________
Employee No:____________
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Name (Last, Given, Middle):
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Address:
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Telephone No:
Cellphone No (if any):
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Date of Birth:
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Sex: Male
Female
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Citizenship:
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GSIS BP No:
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Pag-Ibig ID No:
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PhilHealth No:
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Tin No.:
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Civil Status:
Single/ Widow/ Widower/ Legally Separated (no. of Dependents)
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Head of the Family
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Single with qualified dependents
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Widow/ Widower with qualified dependents
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Legally separated with qualified dependents
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Benefactor of a qualified dependents
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Married
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Number of children below 21 years old: _______
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Husband claims additional exemptions
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Wife claims additional exemptions (attach waiver of husband)
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AUTHORIZED DEDUCTIONS: (Monthly Basis)
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Regular Deductions:
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Life and Retirement: ______________
Medicare: ____________________
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Pag-Ibig: _______________________
Withholding Tax: _______________
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Other Deductions from Government and Private Institutions: (Please indicate if there's any)
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Deduction Code
Name of Loan/ InsurancePeriod Covered
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Prepared by:
Certified Correct:
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MIRACLE FAITH C. SENARIO
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Administrative Officer IV
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OIC, Office of the Administrative Officer V
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Printed Name and Signature of Employee
Printed Name and Signature of Authority
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