Republic of the Philippines

Department of Education
Region XII
DIVISION OF SULTAN KUDARAT
Kenram, Isulan, Sultan Kudarat
Tel/Fax No. 064-471-1007 ◾ Email: depedsk.r12@deped.gov.ph

REQUEST FOR PAYMENT of MATERNITY LEAVE BENEFITS

Date: ____________________

The Schools Division Superintendent

DepEd Division of Sultan Kudarat
Kenram, Isulan, Sultan Kudarat

Sir:

May I request for the payment of my salary for services rendered covering the period from
_________________________________ to ___________________________________. I am
currently assigned at __________________________________________________ School,
_______________________ District as ___________________. Please credit my net salary to:

Bank Account Name: _______________________________

Account Number: __________________________________ (see attached LOI)

May I also request to remit my contribution on premiums to the following:

TAX: TIN #___________________________ (see attached BIR form 1902/2305)

Attached are supporting documents (3 copies each) for your perusal:

_______1. Certified true copy of approved application for leave
_______2. Medical certificate for maternity leave
_______3. Birth Certificate
_______4. Special Order for Reinstatement of Duty
_______5. Special Order for Maternity Leave Benefits
_______6. Latest payslip

Additional Requirement for Unused Maternity Leave:

_______1. Medical Certificate that the employee is physical fit to work
_______2. Certificate of assumption to duty
_______3. Approved DTR

Very truly yours, Noted by:

______________________________ __________________________
Claimant School Head

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To be filled up by Accounting Section:

NAME BASIC PERA TOTAL TAX NET PAY

Certified Funds Available: Approved for Payment:

NOLI M. ASUNCION, CPA LEONARDO M. BALALA, CESE

Accountant III Schools Division Superintendent

Serbisyong may Integridad, Kalidad, Angat at Tapat

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