Date _______________ The Regional Director Department of Education Region IV-A CALABARZON Karangalan Village Cainta, Rizal

Sir/ Madam: Please effect immediate deduction / stoppage of deduction from my monthly salary, if possible effective ______________________________________. DISCONTINUE CODE NO. NAME OF INSURANCE COMPANY AMOUNT 1. 2. 3. 4. 5. 6. CONTINUE 1. 2. 3. 4. 5. 6. 7. ADJUST 1. 2. 3. 4. FROM: TO: Very truly yours, _____________________________ Division No. __________________ Station No. ___________________ Employee No. _________________ CODE NO. NAME OF INSURANCE COMPANY AMOUNT CODE NO. NAME OF INSURANCE COMPANY AMOUNT

NOTED BY: