HQP-TMF-191

(V04, 12/2020)
Pag-IBIG Fund

PAYMENT INSTRUCTION FORM (PIF)

PASAY
____(Pag-IBIG Servicing Branch)____

Employer ID Number : 209547690007

Payment Instruction Date : December 22, 2021

7213 56E2 FAB0

Payment Instruction Number (PIN)

EMPLOYER/BUSINESS NAME : DRSMILE DENTAL CLINIC

ADDRESS AND CONTACT DETAILS

Unit/Room No., Floor Building Name Lot No., Block No. AREA CODE TELEPHONE NUMBER
UNIT D Business (Direct Line)
Phase No. House No. Street Name 8 3531132
734 T ANZURES ST Business (Trunk Line) Local
Subdivision Barangay Municipality
Cell Phone Number
N/A SAMPALOC
09173031394
Province Region Zip Code
Business Email Address
NCR, CITY OF MANILA, FIRST NATIONAL CAPITAL REGION (NCR) 0000 jermaine_delrosario@yahoo.com
DISTRICT

PERIOD COVERED
TYPE OF PAYMENT AMOUNT DUE CLIENT PRINT VALIDATION
From To

MEMBER SAVINGS 11 - 2021 11 - 2021 200.00

TOTAL AMOUNT 200.00

Prepared by: Date:

LORNA TOLENTINO DEL ROSARIO
____ (Name and Designation)_____
SECRETARY 12/22/2021
__________________

REMINDERS:
1. This form is valid from ____(date)____ 01/20/2022
12/22/2021 to ____(date)____. If payment to be made is beyond the reflected validity period, this form will not be accepted
by any accredited collecting partner/s.
2. Please remit MS/pay loan obligation on or before the due date to avoid incurring penalties.

Employer ID Number 209547690007

Total Amount Due Php 200.00
PIN: 721356E2FAB0 TO BE FILLED OUT BY THE PAYOR
DRSMILE DENTAL CLINIC Cash Payment
UNIT D, 734, T ANZURES ST, N/A, SAMPALOC, NCR, CITY OF MANILA,
FIRST DISTRICT, 0000 Check Payment
Check No.
Bank/Branch