This form maybe reproduced and is NOT FOR SALE

RF-1
Revised
EMPLOYER'S
THIS
REMITTANCE
PORTION TO
REPORT
BE FILLED UP BY PHILHEALTH
January2012

1 PHILHEALTH NO. 000000000000 Date Received: ________________________ Action Taken:

By :________________________
EMPLOYER TIN 0
Signature Over Printed Name

2 COMPLETE EMPLOYER NAME

PHI 3 EMPLOYER TYPE 4 REPORT TYPE 5
LH D
EAL A ✘ PRIVATE ✘ REGULAR RF-1
T
THCOMPLETE MAILING ADDRESS E ADDITION TO PREVIOUS RF-
✘ GOVERNMENT ✘
IDE 1 JANUARY 2014
O
0 HOUSEHOLD ✘ DEDUCTION TO PREVIOUS RF-1
NTI TELEPHONE NO. 0 EMAIL ADDRESS F ✘

FIC
6 7
B
8
Fill-out this portion only if declared
10 NHIP PREMIUM
11
PHILHEALTH EMPLOYEE/S INFORMATION I employee/s has not yet been 9 CONTRIBUTION
ATI R issued his/her PIN

ON IDENTIFICATION T
NUMBER (PIN) NAME HDATE OF BIRTH (mm- SEX MONTHLY
S-Separated, NE-No Earnings, NH-
NU LAST NAME SUFFIX FIRST NAME MIDDLE NAME dd-yyyy) (M/F)
SALARY
BRACKET
(MSB)
PS ES Newly Hired / Effectivity Date
(
MB m
1 0 0
ER m

(PI
2
-
d
0 0
N)
3
d
-
0 0
4 y
y
0 0
5 y 0 0
y
6 ) 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0

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22 0 0
23 0 0
24 0 0
25 0 0

12 13 ACKNOWLEDGEMENT RECEIPT (PAR/POR/TRANSACTION REFERENCE NO.) 14 15

SIGNATURE OVER PRINTED NAME
GRAND TOTAL (PS+ES) 0.00 0.00
0 APPLICABLE PERIOD REMITTED AMOUNT ACKNOWLEDGEMENT RECEIPT TRANSACTION DATE
OFFICIAL DESIGNATION

Indicate Total Number of

employees per page JANUARY 0.00 0 (To be accomplished on every page) 0.00 9/11/2019 15:59
DATE

UNDER THE PENALTY OF THE LAW, I HEREBY ATTEST THAT THE ABOVE INFORMATIONS PROVIDED HEREIN ARE TRUE AND CORRECT.
16

Signature over printed name Official Designation Date

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 2 OF 4 PAGES
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Y PHILHEALTH

on Taken:

APPLICABLE
PERIOD

JANUARY 2014

11 EMPLOYEE STATUS

S-Separated, NE-No Earnings, NH-

Newly Hired / Effectivity Date

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 3 OF 4 PAGES
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SIGNATURE OVER PRINTED NAME

OFFICIAL DESIGNATION

9/11/2019 15:59
DATE

marc punzalan PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM | 17 | PAGE 4 OF 4 PAGES