Official Receipt

Region I-Municipal Circuit Trial Court JEP-23-000035642

SAN FABIAN-SAN JACINTO, Pangasinan

Date and Time Paid: Jan 04, 2023 10:52 AM Transaction No.: zFibbaN8pXlk
Date and Time Posted: Jan 04, 2023 10:52 AM Confirmation No.: 9090999931939
Mode of Payment: Online Payment - UPay Assessment No.: MCTC976337222
Name of Payor: John marx Serraon Delos Reference No.: ce14a28d7d174dbcafc73db2543918fe
santos
Nature of Collection: Filing of Applications, Payment Status: PAID
Motions, or Requests
Collection Type: Clearance and Certification Fee - Sec. 8(o)
Case Number/Roll No./MCLE N/A
No./Applicant ID:
Case Title/Particulars: Clearance

Assessment details:

Type of Fund/Nature of Filing Fee Miscellaneous Fee Total Amount

Payment
JDF 9.60 9.60
SAJF 40.40 40.40
LRF 10.00
TOTAL AMOUNT: ₱ 60.00

Payment details:

OR No. Date and Time Amount Paid Running Balance

JEP-23-000035642 Jan 04, 2023 10:52 AM ₱ 60.00 ₱ 0.00
LATEST AMOUNT PAID IN WORDS: SIXTY AND 00/100**

******** NOTHING FOLLOWS ********

NOTE 1: This serves as the Legal Fees Form. Convenience fee or bank charges are not part of the collection of the court.

Payment Confirmed & Verified by:

LORETA N. BAUTISTA
Acting Clerk of Court/Accountable Officer

SCP-JEP Version 3.0 Page 1 of 1 Printed on 01/04/2023 - 11:08 AM