PHILIPPINE OVERSEAS EMPLOYMENT ADMINISTRATION

FM-POEA-04-EF-06D
Effectivity Date: 16 May 2012
OVERSEAS WORKERS WELFARE ADMINISTRATION DO NOT WRITE ON THIS SPACE
PHILIPPINE HEALTH INSURANCE CORPORATION (For POEA, OWWA, Philhealth Use Only)
REQUEST PAYMENT DATE
CG No.:
1. OWWA RPS No.:
Membership________________________ Assessment No.:
INFORMATION SHEET
2. Philhealth/Medicare_________________
_ Assessed
Amount:
POEA:
OFW e-card / ID No: OWWA:
SSS No: 0424652131 PHILHEALTH:
SID No/ISRC No.:
Philhealth No.: 080255832569

I. PERSONAL DATA Changes/s (If Any)

(for balik-manggagawa only)
Name: Juanata Justin Galpao
Family Name(Apelyido) First Name(Pangalan) Middle Name(Gitnang Apelyido)

Address in the Philippines: (Tirahan): Block 5 Lot 18 Galante Steet Villa Remedios Halang Calamba
Laguna Philippines 4027

Telephone No: +63 49 5455889 Cellphone no: +63 936 963 e-mail address: juanata1805@gmail.com
3038

Date of Birth: 07 16 1991 Sex: M F Civil Status:  Single  Widowed

MM DD YYYY  Married  Separated
Place of Birth: Santa Cruz Laguna

SIRB No: ____C1435068_____ Passport No: P1155512B Highest Educational Attainment:

Name of Spouse (If Married): Jazel L. Juanata Mother’s Full Maiden Name: Galpao

Legal Beneficiaries (Mga tatanggap ng benepisyo mula sa OWWA):

Name Relationship to worker Address

B5 L18 Galante Steet Villa Remedios Halang CalambaLaguna
Juanata Myrna Galpao Mother
Philippines,
B5 L18 Galante Steet Villa Remedios Halang CalambaLaguna
Juanata Adriano Castañeda Father
Philippines,

Allottee (itinalaga na padadalhan ng bahagi ng sahod ng OFW /Seafarer):

Juanata Myrna , Juanata Justin

Legal Dependents (Mga tatanggap ng benepisyo mula sa PhilHealth):

Name of Spouse/Children/Parent Sex Relationship of dependent to worker Date of Birth

Juanata, Myrna Galpao F Mother 31/Mar/1960
Juanata, Adriano Castañeda M Father 29/Aug/1964

II. CONTRACT PARTICULARS Changes/s (If Any)

(for balik-manggagawa only)

Name of Principal/ Company/ Employer: Torm A/S

Address: TUBORG HAVNEVEJ 18 Hellerup Denmark e-mail Address: mhrph@torm.com

Name of Vessel/s: TORM CORRIDO Tel No: +45 39 17 92 00

Position of OFW/Seafarer: SECOND OFFICER Contract Duration: Six (6) months

Monthly Salary : 1,256.00 Currency: USD

Last Date of arrival in the Phils of the OFW balik-manggagawa/Seafarer: 09 April 2022

Date of scheduled departure / return of balik-manggagawa to the jobsite: 12 July 2022

Name of Philippine Recruitment/Manning Agency (if applicable): Torm Shipping Phils. Inc.

I hereby certify that the above statements are true and correct and further declare that the above-named dependents have not been declared by my
spouse/brother/sister (Ako ay nagapatunay na ang itaas na pahayag ay totoo at tama at dagdag kong inihahayag na ang mga nasabing makikinabang ay
hindi inihayag ng aking asawa o kapatid)

Justin G. Juanata
_______________________________________
Signature/Thumbmark of OFW/Seafarer