R1 for 12 employees
10
EMP NAME ADDRESS PEN EMPLOYER TYPE TEL # YEAR INCHARGE MONTH POSITION TYPE OF REPORT EMAIL DATE PREPARED # OF EE'S LAST NAME SUFFIX FIRST NAME 1 2 3 4 5 6 7 8 9 10 11 12
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R1 files of Philhealth
Transcript of R1 for 12 employees
EMP NAME
ADDRESS
PEN EMPLOYER TYPETEL # YEARINCHARGE MONTHPOSITION TYPE OF REPORTEMAIL DATE PREPARED# OF EE'S LAST NAME SUFFIX FIRST NAME
123456789
101112
EMPLOYEE COUNT 12 SSS NUMBER ME-5 # / OR # TIN AMOUNT PAID
PRIVATE ALLOTED GS DATE PAID2015 PREPARED BY APPLICABLE MONTH12 DESIGNATION TOTAL RF-1R OVER/UNDER
1/20/2016 10:37PHILHEALTH NO SEX SALARY SB
MIDDLE NAME000000000000
DATE OF BIRTH
TOTAL PS 0.00 LINKSTOTAL ES 0.00NO ALLOTED GS 0.00
DECEMBER TOTAL ARREARS 0.000.00 TOTAL PS & TOTAL ES 0.000.00 TOTAL PS + NO ALLO 0.00
PS ES ALLOTED REMARKS DATE
0.00 0.00 0.000.00 0.00 0.000.00 0.00 0.000.00 0.00 0.000.00 0.00 0.000.00 0.00 0.000.00 0.00 0.000.00 0.00 0.000.00 0.00 0.000.00 0.00 0.000.00 0.00 0.000.00 0.00 0.00
PRINT OUT RF1SAVE TXT
PRINT OUT RF1aSAVE TXTa
REMITTANCE REPORT
000000000000 42015RMEMBERS 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 M5-SUMMARY100000000 00000000 12301899 12GRAND TOTAL0000000000
REMITTANCE REPORT
000000000000 42015RMEMBERS 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 00000000 000000 000000 000000 000000 000000 000000 M5-SUMMARY100000000 00000000 12301899 12GRAND TOTAL0000000000
This form maybe reproduced and is NOT FOR SALE
marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 6 OF 10 PAGES
RF-1 EMPLOYER'S REMITTANCE REPORT THIS PORTION TO BE FILLED UP BY PHILHEALTH
PHILHEALTH NO. 000000000000
EMPLOYER TIN 0
COMPLETE EMPLOYER NAME EMPLOYER TYPE REPORT TYPE
COMPLETE MAILING ADDRESSDECEMBER 2015
TELEPHONE NO. 0 EMAIL ADDRESS 0
EMPLOYEE/S INFORMATION EMPLOYEE STATUS
LAST NAME FIRST NAME MIDDLE NAME PS ES
1 0 0 2 0 0 3 0 0 4 0 0 5 0 0 6 0 0 7 0 0 8 0 0 9 0 0 10 0 0 11 0 0 12 0 0
ACKNOWLEDGEMENT RECEIPT (PAR/POR/TRANSACTION REFERENCE NO.)
GRAND TOTAL (PS+ES) 0.00 0.00
12 APPLICABLE PERIOD REMITTED AMOUNT ACKNOWLEDGEMENT RECEIPT TRANSACTION DATE
DECEMBER 0.00 0 (To be accomplished on every page) 0.00 1/20/2016 10:37
UNDER THE PENALTY OF THE LAW, I HEREBY ATTEST THAT THE ABOVE INFORMATIONS PROVIDED HEREIN ARE TRUE AND CORRECT.
APPLICABLE PERIOD
PHILHEALTH IDENTIFICATION NUMBER (PIN)
PHILHEALTH IDENTIFICATION NUMBER
(PIN)
Fill-out this portion only if declared employee/s has not yet been
issued his/her PIN
NHIP PREMIUM CONTRIBUTION
NAME SUFFIX
DATE OF BIRTH (mm-dd-yyyy)
DATE OF BIRTH (mm-dd-yyyy)
SEX (M/F)
MONTHLY SALARY
BRACKET (MSB)
S-Separated, NE-No Earnings, NH-Newly Hired / Effectivity Date
Indicate Total Number of employees per page
Revised January2012
1
6
2
7 8 9 10 11
14
3 4 5
1512
16
13SIGNATURE OVER PRINTED NAME
OFFICIAL DESIGNATION
DATE
Date Received: ________________________
By :________________________Signature Over Printed Name
Action Taken:
PRIVATE
GOVERNMENT
HOUSEHOLD
REGULAR RF-1
ADDITION TO PREVIOUS RF-1
DEDUCTION TO PREVIOUS RF-1
This form maybe reproduced and is NOT FOR SALE
marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 7 OF 10 PAGES
Signature over printed name Official Designation Date
This form maybe reproduced and is NOT FOR SALE
marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 8 OF 10 PAGES
SIGNATURE OVER PRINTED NAME
This form maybe reproduced and is NOT FOR SALE
marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 9 OF 10 PAGES
This form maybe reproduced and is NOT FOR SALE
marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 10 OF 10 PAGES
RF-1 EMPLOYER'S REMITTANCE REPORT THIS PORTION TO BE FILLED UP BY PHILHEALTH
PHILHEALTH NO. 000000000000
EMPLOYER TIN 0
COMPLETE EMPLOYER NAME EMPLOYER TYPE REPORT TYPE
COMPLETE MAILING ADDRESSDECEMBER 2015
TELEPHONE NO. 0 EMAIL ADDRESS 0
EMPLOYEE/S INFORMATION EMPLOYEE STATUS
LAST NAME FIRST NAME MIDDLE NAME PS ES
1 0 0 2 0 0 3 0 0 4 0 0 5 0 0 6 0 0 7 0 0 8 0 0 9 0 0 10 0 0 11 0 0 12 0 0
ACKNOWLEDGEMENT RECEIPT (PAR/POR/TRANSACTION REFERENCE NO.)
GRAND TOTAL (PS+ES) 0.00 0.00
12 APPLICABLE PERIOD REMITTED AMOUNT ACKNOWLEDGEMENT RECEIPT TRANSACTION DATE
DECEMBER 0.00 0 (To be accomplished on every page) 0.00 1/20/2016 10:37
UNDER THE PENALTY OF THE LAW, I HEREBY ATTEST THAT THE ABOVE INFORMATIONS PROVIDED HEREIN ARE TRUE AND CORRECT.
Signature over printed name Official Designation Date
APPLICABLE PERIOD
PHILHEALTH IDENTIFICATION NUMBER (PIN)
PHILHEALTH IDENTIFICATION NUMBER
(PIN)
Fill-out this portion only if declared employee/s has not yet been
issued his/her PIN
NHIP PREMIUM CONTRIBUTION
NAME SUFFIX
DATE OF BIRTH (mm-dd-yyyy)
DATE OF BIRTH (mm-dd-yyyy)
SEX (M/F)
MONTHLY SALARY
BRACKET (MSB)
S-Separated, NE-No Earnings, NH-Newly Hired / Effectivity Date
Indicate Total Number of employees per page
Revised January2012
1
6
2
7 8 9 10 11
14
3 4 5
1512
16
13SIGNATURE OVER PRINTED NAME
OFFICIAL DESIGNATION
DATE
Date Received: ________________________
By :________________________Signature Over Printed Name
Action Taken:
PRIVATE
GOVERNMENT
HOUSEHOLD
REGULAR RF-1ADDITION TO PREVIOUS RF-1DEDUCTION TO PREVIOUS RF-1
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