HQP-PFF-053

MEMBER'S CONTRIBUTION Pag-IBIG EMPLOYER'S ID NUMBER

209678910001
REMITTANCE FORM (MCRF)
NOTE: PLEASE READ INSTRUCTIONS AT THE BACK.
EMPLOYER/BUSINESS NAME JULIUS K. QUIAMBAO (JKQ) MEDICAL AND WELLNESS CENTER INC.
BANI, BAYAMBANG, PANGASINAN
EMPLOYER/BUSINESS ADDRESS PERIOD COVERED
Unit/Room No.,Floor Building Name Lot No., Bock No., Phase No., House No. Street Name
JANUARY 2022

Subdivision Barangay Municipality/City Province/State/Country (if abroad) ZIP Code TELEPHONE NUMBER

BANI BAYAMBANG PANGASINAN 2423

APPLICATION/ MEMBERSHIP NAME OF MEMBERS PERIOD EMPLOYER
MID No.
AGREEMENT No. PROGRAM Last Name First Name Name Ext.(Jr.,III,etc.) Middle name COVERED EE SHARE ER SHARE TOTAL REMARKS
121143870268 F1 ABARCAR MARJOHN FRAGATA 202201 100.00 100.00 200
102002929357 F1 ALVAREZ RAMIL NATY 202201 100.00 100.00 200 NEW
102002922732 F1 ALVAREZ PAULO MAMARIL 202201 100.00 100.00 200
121284024358 F1 AQUINO MARCELINO DE VERA 202201 100.00 100.00 200
121284098984 F1 ASUNCION MARIO DUMLAO 202201 100.00 100.00 200
121075448162 F1 BELEN CHRISTOPHER DELA CRUZ 202201 100.00 100.00 200
121284677833 F1 BONITA MICHAEL DE GUZMAN 202201 100.00 100.00 200
121216946672 F1 CAYABYAB ARCHCEL SALANDANAN 202201 100.00 100.00 200
121097973734 F1 CALANGIAN VERGELIO DUMALANTA 202201 100.00 100.00 200
121284110386 F1 CALIMLIM JOSHUA JUDE CAYABYAB 202201 100.00 100.00 200
121284115835 F1 CAYABYAB LEANDRO DELA ROSA 202201 100.00 100.00 200
121284683205 F1 CAYABYAB SALVADOR JR MEJIA 202201 100.00 100.00 200
121284121153 F1 DANNANG JEFFREY ALVAREZ 202201 100.00 100.00 200
121284122297 F1 DE GUZMAN TOMAS CAYABYAB 202201 100.00 100.00 200
121284049858 F1 DE VERA GERALD DALOPE 202201 100.00 100.00 200
121284123396 F1 DE VERA JOHN MARK SALINAS 202201 100.00 100.00 200
121284123474 F1 DE VERA MARK CALIMLIM 202201 100.00 100.00 200
121284031707 F1 ESTRADA ELPIDIO ISLA 202201 100.00 100.00 200
121109593346 F1 FELIPE NICKSON ESTABILLO 202201 100.00 100.00 200
121016057510 F1 FERNANDEZ MARK ARTHUR ROBISO 202201 100.00 100.00 200
121206681396 F1 FUENZALIDA JOHNNY BOY MERIN 202201 100.00 100.00 200
121284075703 F1 GABAYNO BENGIE LOZANO 202201 100.00 100.00 200
121284032430 F1 GALLARDO RAUL LEBRIS 202201 100.00 100.00 200
121036277849 F1 GALSIM BERNALDO NATE 202201 100.00 100.00 200 NEW
121043952269 F1 GONZALES GILBERTO GONZALES 202201 100.00 100.00 200 NEW
121122586584 F1 GONZALES GONZALO GONZALES 202201 100.00 100.00 200
121254689393 F1 GONZALES GREGORY GONZALES 202201 100.00 100.00 200
121097803782 F1 GONZALES LEDO ARIBON 202201 100.00 100.00 200
121284036193 F1 JUNIO MARK CANDELARIO 202201 100.00 100.00 200
121283993280 F1 MAGTAAN WILLIAM DIAZ 202201 100.00 100.00 200
121284478174 F1 MALICDEM JESTONI JIMENEZ 202201 100.00 100.00 200
121284668062 F1 MALICDEM KING JUNE JIMENEZ 202201 100.00 100.00 200
121289440675 F1 PACIA JOSE STEPHEN BALASICO 202201 100.00 100.00 200
121288915090 F1 OCAMPO GARY SABANGAN 202201 100.00 100.00 200
121284194479 F1 REBUSURA JOMAR DE VERA 202201 100.00 100.00 200
121284142992 F1 SIMPLICIANO MICHAEL VIRTUDES 202201 100.00 100.00 200
121090866447 F1 SISCON ALLAN CAYABYAB 202201 100.00 100.00 200
121215975769 F1 SOTTO MANDY PADUA 202201 100.00 100.00 200 NEW
121224513959 F1 TIBAY JAYLORD VILLANUEVA 202201 100.00 100.00 200
121045950415 F1 TUPPAL CARLOS BAUTISTA 202201 100.00 100.00 200
121284017097 F1 VILLANUEVA RYAN EVANGELISTA 202201 100.00 100.00 200
121284119097 F1 VILLANUEVA RONNIE ILUMIN 202201 100.00 100.00 200
121036388386 F1 ZAPATERO EDUARDO JR CALACHAN 202201 100.00 100.00 200
TOTAL FOR THIS PAGES 4,300.00 4,300.00 PHP 8,600.00
GRAND TOTAL IF LAST PAGE 4,300.00 4,300.00 PHP 8,600.00
EMPLOYER CERTIFICATION
I hereby certify under pain of perjury that the information given and all statements made herein are true and correct to the best of my knowledge and belief. I further
certity that my signature appering herein is genuine and authentic.
HUMAN RESOURCE MANAGEMENT OFFICE,
MARICHU P. DE VERA HEAD 01/31/2021
HEAD OF OFFICE OR AUTHORIZED SIGNATORY DESIGNATION/POSITION DATE

(Signature Over Printed Name)

THIS FORM MAY BE REPRODUCED. NOT FOR SALE. Rev. 00, 02/2013
 HQP-PFF-053

MEMBER'S CONTRIBUTION Pag-IBIG EMPLOYER'S ID NUMBER

209678910001
REMITTANCE FORM (MCRF)
NOTE: PLEASE READ INSTRUCTIONS AT THE BACK.
EMPLOYER/BUSINESS NAME
JULIUS K. QUIAMBAO (JKQ) MEDICAL AND WELLNESS CENTER INC.
EMPLOYER/BUSINESS ADDRESS BANI, BAYAMBANG, PANGASINAN PERIOD COVERED
Unit/Room No.,Floor Building Name Lot No., Bock No., Phase No., House No. Street Name
JANUARY 2022

Subdivision Barangay Municipality/City Province/State/Country (if abroad) ZIP Code TELEPHONE NUMBER

BANI BAYAMBANG PANGASINAN 2423

APPLICATION/ MEMBERSHIP NAME OF MEMBERS PERIOD EMPLOYER
MID No.
AGREEMENT No. PROGRAM Last Name First Name Name Ext.(Jr.,III,etc.) Middle name COVERED EE SHARE ER SHARE TOTAL REMARKS
121282976148 F1 AMBAT LARISA MAE CABALLERO 202201 100.00 100.00 200.00
121117912410 F1 AQUINO KERBY VIRTUDES 202201 100.00 100.00 200.00
121089751017 F1 BALLESTEROS ELMER MACARAEG 202201 100.00 100.00 200.00 NEW
121283980369 F1 BASAN YVONNE SAMSON 202201 100.00 100.00 200.00
121029443662 F1 BOHOL GAVINO JR RESURRECTION 202201 500.00 100.00 600.00 NEW
121133302852 F1 BONZON JANNINA ORDINARIO 202201 100.00 100.00 200.00 NEW
121224779266 F1 CENTINO LORENZO JR. FERNANDEZ 202201 100.00 100.00 200.00
121207358653 F1 DORADO MARK JOSEPH PULIDO 202201 100.00 100.00 200.00
109000146052 F1 DELA CRUZ MARS SOLOMON 202201 100.00 100.00 200.00
121024917690 F1 DELOS REYES WINSTON MANSANO 202201 100.00 100.00 200.00 NEW
121272552354 F1 DE VERA JESSICA CARANTO 202201 100.00 100.00 200.00
121198402383 F1 DE VERA MARICHU PEREZ 202201 500.00 100.00 600.00
121178174709 F1 DONATO MICHAEL JOHN CABADDU 202201 500.00 100.00 600.00
121137414588 F1 EGOT JERIKA MAY TOLEDO 202201 100.00 100.00 200.00
121171416482 F1 ELGIN JULIUS ALCANTARA 202201 100.00 100.00 200.00
107000775500 F1 FLORES LORETO JR DE VERA 202201 500.00 100.00 600.00
121141391553 F1 GONZALES IRISH JOY DE GUZMAN 202201 100.00 100.00 200.00
121284930389 F1 HAO JOHN LUIS LCASTRO 202201 100.00 100.00 200.00 NEW
121208589374 F1 LAPID DIANA JOY MEJORADA 202201 500.00 100.00 600.00
121078711688 F1 LOMIBAO JERRY PADUA 202201 100.00 100.00 200.00
121289337728 F1 MACARAEG ACE MONSOUR NAVARRO 202201 100.00 100.00 200.00
121285294481 F1 MALICDEM GERALD DELA CRUZ 202201 100.00 100.00 200.00
121165367671 F1 MENDOZA JOMAR DE GUZMAN 202201 500.00 100.00 600.00
121085740696 F1 MANGLALLAN IRIS CAYABYAB 202201 100.00 100.00 200.00 NEW
121011810506 F1 MUENA ARNELIO FLORES 202201 500.00 100.00 600.00
121260479439 F1 RAMOS JOMER MARZAN 202201 100.00 100.00 200.00
121289448154 F1 RAÑOLA ARCE REYES 202201 100.00 100.00 200.00
121117332439 F1 PANIDA JASON QUINTANS 202201 100.00 100.00 200.00
121244194227 F1 RAMOS MARK TIMTIM 202201 100.00 100.00 200.00
121267867923 F1 RAYRAY ROBERT BENSON GUTIERREZ 202201 500.00 100.00 600.00
121230304095 F1 SALINAS MANUEL JOHN CURAMING 202201 100.00 100.00 200.00 NEW
121289440306 F1 SANTOS MELCHOR JR. ORCAS 202201 100.00 100.00 200.00 NEW
109000497491 F1 TERRADO EMMANUEL CATABONA 202201 500.00 100.00 600.00
121138899286 F1 TILLAY RODWELL DE GUZMAN 202201 100.00 100.00 200.00 NEW
121230852728 F1 TORRES JILIMAICA MAGALONG 202201 100.00 100.00 200.00
121227212992 F1 VALENTON JESSIE JAMES ESPIQUE 202201 100.00 100.00 200.00
121268717754 F1 VELASCO ELLIZA RIVERA 202201 100.00 100.00 200.00
121184464116 F1 YOHANON JOHN PAUL FAUSTO 202201 100.00 100.00 200.00

TOTAL FOR THIS PAGE 7,400.00 3,800.00 PHP 11,200.00

GRAND TOTAL IF LAST PAGE 7,400.00 3,800.00 PHP 11,200.00
EMPLOYER CERTIFICATION
I hereby certify under pain of perjury that the information given and all statements made herein are true and correct to the best of my knowledge and belief. I further
certity that my signature appering herein is genuine and authentic.
HUMAN RESOURCE MANAGEMENT OFFICE,
MARICHU P. DE VERA HEAD 01/31/2022
HEAD OF OFFICE OR AUTHORIZED SIGNATORY DESIGNATION/POSITION DATE

(Signature Over Printed Name)

THIS FORM MAY BE REPRODUCED. NOT FOR SALE. Rev. 00, 02/2013