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MEMBER’S REQUEST FORM

JULY 04, 2023

Date

The Chief
Regional Payroll Services Unit
DepED Regional Office VI
Duran Street, Iloilo City

Dear Sir/Madam:

Please effect the following request/s from my Monthly Salary

Account Date of Effectivity


Nature of Request Account Name (not your name) Amount
Code Start End
( ) DEDUCT

( ) STOP
For Loan/s: Attach Full
Payment Official
Receipt/Certification

(P) ADJUST GSIS EMERGENCY LOAN 0704 1,070.54 12/2022 01/2026


MPL 1252 3,656.67 03/2023 04/2033
(GSIS EMERGENCY LOAN) 1,262,31 07/2020 09/2023
(MPL) 3,364.13 10/2022 09/2032

Very truly yours,

________________ AILEEN M. MORDICE __________________


(Signature over Printed Name)

Employee Number: _4251327_____________________

Station Code: _017_________________________

Division Code: _035_________________________

Contact Number: _034-7090153/Div of Neg Occ-DPSU

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