REQUEST FORM FOR STOPPAGES

DATE: July 29 , 2019 (2ND REQUEST)

The Chief
Regional Payroll Services Unit
Department of Education
Regional Office No. VIII
Candahug, Palo, Leyte

Dear Sir/Madam:

May I request to please STOP the following deduction in my payroll register.

ACCOUNT ACCOUNT POLICY AMOUNT EFF. DATE TERMINATION

CODE NAME NUMBERS

0142-A FORTUNE LIFE ______________ 350.00 MARCH 2016 FEBRUARY 2018

INS. CO.

REASON/S

It had been terminated last February 2018, but until I’m still deducted

I understand that the above request shall be acted upon in accordance with the existing
policies and procedures of the Department.

Very truly yours,

JOAN PARRILLA DALUMPINES

(Signature over printed name)
EMPLOYEE NUMBER: 4942122
DIVISION NUMBER: 096
STATION NUMBER: 003
GSIS POLICY NUMBER: 2003460315
TIN: 939654756
BIRTHDATE: DECEMBER 27, 1979
CONTACT NUMBER: 09495014132