TEACHER/EMPLOYEE INDIVIDUAL RECORD FORM

Division: Station:
Division Code: Station Code: Employee No.:
Name (Last, Given, Middle):
Address:
Telephone No.: Cellular Phone No. (If Any)
Date of Birth: (MM/DD/YYYY) Citizenship: FILIPINO
Sex: ✘ Male Female
Position: Employment Status: Permanent Basic Salary:
Business Partner No.: Pag-ibig ID No.:
Philhealth Number: TIN Number:
Civil Status: ✘ Single/Widow/Widower/Legally Separated (No dependents)
Head of the Family
Single with qualified dependent Legally separated with qualified dependent
Widow/Widower with qualified dependent Benefactor of a qualified senior citizen
Married
Number of children below 21 years old
Husband claims additional exemption
Husband claims additional exemption (attach waiver of husband)

AUTHORIZED DEDUCTIONS: (Monthly Basis)

Regular Deductions:
Life and Retirement: Philhealth:
Pag-ibig: Withholding Tax:

Other deductions from Government and Private Institutions: (please indicate if there's any)
Deduction Code Name of Loan/Insurance Period Covered

PREPARED BY: CERTIFIED CORRECT:

PRINTED NAME & SIGNATURE PRINTED NAME & SIGNATURE

OF TEACHER/PERSONNEL OF PRINCIPAL/TEACHER-IN
CHARGE/ADMIN. OFFICER