Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

www.philhealth.gov.ph

SPA No. : SPA100008919757

Applicable Period : 02-2017
Document Control Number : 00704000067669800642
Date/Time Generated : 10/02/2018 20:42:05
Date Received : 02/21/2018 13:15:28
Report Type : Regular
EMPLOYER'S REMITTANCE REPORT
PhilHealth Number : 007040000676
Employer Name : JDN MEMORIAL AGAPE CHRISTIAN ACADEMY INC (FORMERLY: LPI AGAPE CHRISTIAN ACADEMY INC)
Employer Address : BONGABON NUEVA ECIJA
Employer TIN : 248062751000
Employer Type : Private
No. PhilHealth No. Surname Given Name Middle Name PS ES Status | Remarks
1 210501592395 AGUILAR JENELYN PICO 100.00 100.00 A
2 210500408841 BALALA NAOMI DELA CRUZ 125.00 125.00 A
3 070503575297 DELA CRUZ GEORGE PISARAS 225.00 225.00 A
4 070503575300 DELA CRUZ SONIA CAMPOS 162.50 162.50 A

Subtotal 612.50 612.50

GRAND TOTAL 1,225.00

Remitted Amount : 1,225.00

POR No. : 69800642
Transaction Date : 03/14/2017
No. of Employees : 4
Status Report : Posted
Date Posted : 02/21/2018

This is an EPRS generated Employer Remittance Report. Certification of employer is not required.