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LATEST PAYMENT: DO NOT WRITE ON THIS SPACE

DATE: _ (For POEAandOWWA,PhilhealthUseOnly)


1.0WWA CG No.: _
MEMBERSHIP: _ PHILIPPINE OVERSEAS EMPLOYMENT ADMINISTRATION
RFP No.: _
OVERSEAS WORKERS WELFARE ADMINISTRATION Assessment No.: _
1. PHILHEALTt-V
PHILIPPINE HEALTH INSURANCE CORPORATION
Assessed Amount:
MEDICARE: POEA.: _
OWWA: _
PHILHEALTH: _

o Single o Widowed
o Married o Separated

Name of Spouse (if married): _


Legal Beneficiaries (OWWA Insurance) (Mga tatanggap ng benepisyo sa OWWA):
Name

ontact Particulars of OFW


Name of Principal/Company/Employer:
Address:
Jobsite/Country of Destination: _ Telephone No:: _

Position of OFW: Fax No.lE-Mail Address: _


Contract Duration: __ months Monthly Salary _
Last day of arrival of vacationing worker in the Phils.:

Date of scheduled departure/Return of OFW to the jobsite: _


Name of Agency (if applicable): _

Signature of Worker/ Approval of Authorized Agency


Thumbmark Representative (if agency-hired)

o Single o Widowed
o Married o Separated
Name of Spouse (If Married): _
Dependents (Mga makikinabang): Relationship of Dependent
Name of Children/Parent to Worker

I hereby certify that the above statements are true and correct and further declare that the above-named dependents have not been declared by my
spouse/b rotherIsiste r.

(Ako ay nagpapatunay na ang nasa itaas na pahayag ay totoo at tama at dagdag ko ng inihahayag na ang mga nasabing makikinabang sa itaas ay hindi
inihayag ng aking asawa 0 kapatid).