HQP-PFF-053

MEMBER'S CONTRIBUTION Pag-IBIG EMPLOYER'S ID NUMBER

REMITTANCE FORM ( MCRF ) 2075-6066-0005

EMPLOYER/BUSINESS NAME
UKEBOX CORP.
EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No Street Name
Space #PVGF011R G/F MANHATTAN PARKVIEW ARANETA CENTER
Subdivision Barangay Municipality/City Province/State/Country (if abroad) Zip Code
SOCORRO QUEZON CITY 1109
Pag- PERIOD MEMBERSHIP CONTRIBUTIONS
MEMBERSHIP
NAME OF EMPLOYEES COVERED MONTHLY
IBIG MID NO./ RTN PROGRAM
NAME EXT. Middle Name COMPENSATION
ACCOUNT NO, Last Name First Name EE ER REMARKS

(JR., III, ETC) SHARE TOTAL

SHARE

1210-8063-2299 Cosejo Christian Paul 201807 12,048.00 100 100 200

12/01/1982 Gonzales Pasquinel 201807 12,048.00 100 100 200
1211-2252-3603 Nebrida Brigette Anne 201807 12,048.00 100 100 200

TOTAL FOR THIS PAGE 300 300 600

GRAND TOTAL (if last page) 300 300 600
EMPLOYER CERTIFICATION

I hereby certify under pain of perjury that the information given and all statements made herein are true and correct to the best of my knowledge and belief. I further
certify that my signature appearing herein is genuine and authentic.

TIMOTHY GREGORY ALEGRO PRESIDENT

HEAD OF OFFICE OR AUTHORIZED REPRESENTATIVE DESIGNATION/POSITION DATE
(Signature Over Printed Name)

THIS FORM MAY BE REPRODUCED. NOT FOR SALE (REVISED 7/2012)