RF-1

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATIO F O R P H I L H E A L T H U S E
REVISED JAN 2002
EMPLOYER'S MONTHLY
REMITTANCE REPORT Date Screened: Action Taken: Date Screened: Action Taken
1
PHILHEALTH NO. ###
0 1 0 #
0##
###
###
###
### 1 3 By: By:

EMPLOYER TIN ###

2 ### 0 #
6## ###
###
### ### ###
0 Signature over Printed Name Signature over Printed Name

2 3 EMPLOYER TYPE 4 TYPE OF REPORT 5 APPLICABLE MONTH

COMPLETE EMPLOYER NAME PAULINE'S GROUP INC. (Pauline's Ent.) Regular EMPLOYER'S SSS NO. Regular RF-1 April ###
200
COMPLETE MAILING ADDRESS C3 FREB Bldg., Villa Donata, Alabang X Private 0 3 - 9###
0 6 0 8 2 0 Addition to previous RF-1

Muntinlupa City TELEPHONE NO. 809-3535 x Government EMPLOYER'S SSS/GSIS POLICY NO. Deduction to previous RF-1

Household

6 7 8 9 NHIP PREMIUM CONTRIBUTIONS 10 REMARKS

NAME OF EMPLOYEE/S
MONTHLY April S - Separated, NE - No Earning, NH - Newly Hired
COMPENSATION
PhilHealth ID No./SSS ID BRACKET
No./GSIS Policy No. Date of
Surname Given Name MIDDLE NAME PS ES
Effectivity

1 Piodo Romeo Gemao 19-0506618731 12 187.50 187.50

2 Pulido Allanbert Alazaga 04-31948786 4 87.50 87.50
3 Que Bernadette Bautista 02-2093756-8 4 87.50 87.50
4 Ramos Minda De Pedro 19-0514880577 4 87.50 87.50
5 Ramos Miriam De Pedro 19-0514880585 6 112.50 112.50
6
7 Regalado Josephine Agao 07-0253307445 4 87.50 87.50
8 Roberto Angelica Frances Datiles 03-0002038710 12 187.50 187.50
9 Roberto Faustino Sanchez 19-0500567558 22 375.00 375.00
10 Roberto Loralie Bautista 33-91859439 8 137.50 137.50
11 Roberto Ma. Pauline Bautista 19-0514880631 5 137.50 137.50
12
13 Rosialda Nonie Ramos 19-0514880593 6 112.50 112.50
14 Tolentino Lani Tanudra 34-0454307-6 6 112.50 112.50
15 Vargas Julito Plapa 01-0504783661 5 - - S OCT.
16
17 NH Aug. 2009
11 ME-5 SUMMARY OF CONTRIBUTION PAYMENTS 12 13 Certified Correct:
ME-5 (PS + ES)
Month Total Contribution Date Paid No. of Employees SUBTOTAL 1,712.50 1,712.50 - - - - ERLINDA B. ROBERTO
Reconcilation No.
OCTOBER 8,950.00 219900266 11/10/09 49 3,425.00 - - SIGNATURE OVER PRINTED NAME
(To be accomplished on every page) VP & Treasurer
4,475.00 4,475.00 - - - - OFFICIAL DESIGNATION
GRAND TOTAL (PS + ES)
8,950.00 - -
(To be accomplished on every page) DATE
PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM 14 PAGE 3 OF 3 PAGES
 RF-1
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION F O R P H I L H E A L T H U S E
REVISED JAN 2002
EMPLOYER'S QUARTERLY
REMITTANCE REPORT Date Screened: Action Taken: Date Screened: Action Taken
1
PHILHEALTH NO. ###
### ###
- ###
###
###
### ###
1 ###
### ###
- By: By:

EMPLOYER TIN ###

###
### ###
- ###
### - ###
8 ### - Signature over Printed Name Signature over Printed Name

2 3 EMPLOYER TYPE 4 TYPE OF REPORT 5 APPLICABLE MONTH

COMPLETE EMPLOYER NAME PAULINE'S GROUP INC. (Pauline's Ent.) Regular EMPLOYER'S SSS NO. Regular RF-1 April ###
200
COMPLETE MAILING ADDRESS C3 FREB Bldg., Villa Donata, Alabang X Private 0 3 - 9###
0 6 0 8 2 0 Addition to previous RF-1

Muntinlupa City TELEPHONE NO. 809-3535 x Government EMPLOYER'S SSS/GSIS POLICY NO. Deduction to previous RF-1

Household

6 7 8 9 NHIP PREMIUM CONTRIBUTIONS 10 REMARKS

NAME OF EMPLOYEE/S
MONTHLY April S - Separated, NE - No Earning, NH - Newly Hired
COMPENSATION
PhilHealth ID No./SSS ID
BRACKET Date of
Surname Given Name M.I. No./GSIS Policy No. PS ES
Effectivity

1
2
3
4

5
6
7
8
9
10
11
12
13
11 ME-5 SUMMARY OF CONTRIBUTION PAYMENTS 12 13 Certified Correct:
ME-5 Date (PS + ES)
Month/Quarter Total Contribution No. of Employees SUBTOTAL - - - - - - ERLINDA B. ROBERTO
Reconcilation No. Paid
- - - - SIGNATURE OVER PRINTED NAME
(To be accomplished on every page) VP & Treasurer
- - - - OFFICIAL DESIGNATION
GRAND TOTAL (PS + ES)
- -
(To be accomplished on every page) DATE
PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM 14 PAGE 3 OF 3 PAGES
 Republic of the Philippines
RF-1 PHILIPPINE HEALTH INSURANCE CORPORATIO F O R P H I L H E A L T H U S E
REVISED JAN 2002
EMPLOYER'S MONTHLY
REMITTANCE REPORT Date Screened: Action Taken: Date Screened: Action Tak
1
###
PHILHEALTH NO. ######
0 ### ###
0 ### ###
2 ###
1 By: By:

EMPLOYER TIN ### ###

2 ### ###
6 ###
8 8 Signature over Printed Name Signature over Printed Name

2 ###EMPLOYER TYPE 4 TYPE OF REPORT 5 APPLICABLE MONTH

COMPLETE EMPLOYER N PAULINE'S GROUP INC. (Pauline's Enterprises) Regular EMPLOYER'S SSS NO. Regular RF-1 April 200 9
COMPLETE MAILING ADD C3 FREB Bldg., Villa Donata, Alabang X Private 0 3 - 9###
0 6 0 8 2 0 Addition to previous RF-1

Muntinlupa City TELEPHONE NO. 809-3535 x Government EMPLOYER'S SSS/GSIS POLICY NO. Deduction to previous RF-1

Household

6 7 8 9 NHIP PREMIUM CONTRIBUTIONS 10 REMARKS

NAME OF EMPLOYEE/S MONTHLY
COMPENSA April S - Separated, NE - No Earning, NH - Newly Hired
PhilHealth ID No./SSS ID TION
No./GSIS Policy No. BRACKET Date of
Surname Given Name MIDDLE NAME PS ES
Effectivity

1 Gomba Mervie Albino 33-70078905 6 112.50 112.50

2 Jundis Ronaliza Mendoza 19-0514880577 4 87.50 87.50
3 Jose Janet Magsakay 33-9335068-4 4 87.50 87.50
4 Igloria Imee Ann Valledor 19-0900774730 3 75.00 75.00
5 Labrador Nieves Daguio 19-0514880542 4 87.50 87.50
6 Liansing Alma Umadhay 07-15846740 4 87.50 87.50
7 Lopez Rowena Cabrera 19-0514880593 4 100.00 100.00
8 Macasadya Jeniel Rocamura 09-050119712-1 4 87.50 87.50 NH 10/01/09
9 Malihan Nemia Dayot 19-089540832-1 4 87.50 87.50 NH 10/01/09
10 Maraa Virginia Fortaleza 33-38118014 1 50.00 50.00
11 Marco Alice Sibulo 33-20433176 1 50.00 50.00
12 Nollido Emilia Molino 0368786671 11 175.00 175.00
13
14 Paberan Ana Mie Delegencia 33-89185902 1 50.00 50.00
15 Paberan Marycris Delegencia 34-1666094-7 4 50.00 50.00
16 Pagunsan Ma. Consuelo Ledesma 19-0512538723 4 87.50 87.50
17
11 ME-5 SUMMARY OF CONTRIBUTION PAYMENTS 12 13 Certified Correct:
ME-5 (PS + ES)
Date
Month Total Contribution Reconcilation No. of Employees SUBTOTAL 1,275.00 1,275.00 - - - - ERLINDA B. ROBERTO
Paid
No.
OCTOBER 8,950 219900266 11/10/09 49 (To be accomplished on every 2,550.00 - - SIGNATURE OVER PRINTED NAME
page) VP & Treasurer
OFFICIAL DESIGNATION
GRAND TOTAL (PS + ES)
(To be accomplished on every
page) DATE
PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM 14 PAGE 2 OF 3 PAGES
 Republic of the Philippines

RF-1 PHILIPPINE HEALTH INSURANCE CORPORA F O R P H I L H E A L T H U S E

REVISED JAN 2002 EMPLOYER'S MONTHLY REMITTANCE REPORT Date Screened: Action Taken: Date Screened: Action Take
1
PHILHEALTH NO.### 0 1 0 0 0 0 2 ###
0 45 By: By:

EMPLOYER TIN ### 4 6 0 9 7 ###

9 4 Signature over Printed Name Signature over Printed Name

2 ###EMPLOYER TYPE 4 TYPE OF REPORT 5 APPLICABLE MONTH

COMPLETE EMPLOYER NAME ALABANG INTERIORS ACCESSORIES CORP. Regular EMPLOYER'S SSS NO. Regular RF-1 April 2010
COMPLETE MAILING ADDRESS 3RD Flr. FREB Bldg., Villa Donata, Alabang , X Private ###
### ###
- ###
###
###
###
###
### ###
- Addition to previous RF-1

Muntinlupa City TELEPHONE NO. 772-1867 x Government EMPLOYER'S SSS/GSIS POLICY NO. Deduction to previous RF-1

Household

6 7 MONTHL
8 9 NHIP PREMIUM CONTRIBUTIONS 10 REMARKS
NAME OF EMPLOYEE/S Y
COMPE April S - Separated, NE - No Earning, NH - Newly Hired
NSATIO
PhilHealth ID No./SSS ID N
No./GSIS Policy No. Date of
Surname Given Name MIDDLE NAME BRACKE PS ES
Effectivity
T

1 Abasta Noel Ocariz 33-7294659-8 62.50 62.50

2 Aquino Angelique Gianan 34-1276358-9 4 87.50 87.50
3 Bucarile Mary Jane Gianan 33-5623752-4 4 87.50 87.50
4 De Jesus Mina Macalalad 01-050737101-4 3 75.00 75.00
5 De Lios Jaqueline Valenzuela 19-090252471-5 4 87.50 87.50
6 De Ramos Jelyn Delos Santos 07-2138836-0 4 87.50 87.50
7 Flores Christopher Longa 339198631 5 100.00 100.00
8 Gan Cokie Ann Hallegano 01-0251489462 6 112.50 112.50
9 Lopez Gilbert Tawat 01-050805265-6 4 87.50 87.50
10 Orilla Ronald CARAMORA 01-050776957-3 4 NE
11 Orticio Rowena Tualla 01-050786090-2 4 87.50 87.50
12 Parado Christopher Pealoza 34-0612086-6 4 100.00 100.00
13 Perez Cristina Loteria 01-050805264-8 4 87.50 87.50
14 Rempis Bernardino Suarnava 01-050108550-8 6 112.50 112.50
15 Roberto Robert Bautista 01-050608988-9 5 137.50 137.50
16 Villas Rosemarie Dedal 01-050154447-2 4 87.50 87.50
17 Villena Bonifacio Tabianan 01-050236044-8 4 87.50 87.50
11

11 ME-5 SUMMARY OF CONTRIBUTION PAYMENTS 12 13 Certified Correct:

ME-5 Reconcilation Date (PS + ES)
Month/Quarter Total Contribution No. of Employees SUBTOTAL 1,487.50 1,487.50 - - - - ROBERT B ROBERTO
No. Paid
April 2,975.00 217453176 05/11/10 16 (To be accomplished on every 2,975.00 - - SIGNATURE OVER PRINTED NAME
page) PRESIDENT
OFFICIAL DESIGNATION
GRAND TOTAL (PS + ES)
(To be accomplished on every
page) DATE
PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM 14 PAGE 1 OF 1 PAGE 1
 I N S T R U C T I O N S

Note: The corresponding instructions per numbered-box are enumerated below.

Box 1: Write the COMPLETE Employer TIN and PhilHealth No. in corresponding boxes. Box 13: Affix signature and print complete name, designation and date of certification of authorized officer certifying the report.

Box 2: Write the COMPLETE Employer Name, Address and Telephone No. DO NOT ABBREVIATE.
Box 3: Check applicable box for Employer Type. Indicate the Employer's SSS No. for regular private employers. For government
employers, ensure that the Employer TIN in Box 1 is filled-up. For Household employers, write Employer's SSS No./GSIS Policy No.
Box 4: Check the applicable box for Type of Report. For adjustment on remittance report of previous quarter, use a separate RF-1 form and
check the box corresponding to "Addition to Previous RF-1" or "Deduction to Previous RF-1", as the case may be. Write only the names of
the additional employees that were not declared or name of employees to be deleted if they were erroneously declared in the previous
report. If an underpayment results due to this correction, please remit the amount due to PhilHealth . Use separate/different set of RF-1
form for each quarter when reporting previous payments or for late payments made on previous quarter(s).
Box 14: Always indicate page number and total number of pages at each page of the form.
Submit Orignal Copy of this duly accomplished form every quarter ending March, June, September and December with the
corresponding copies of the validated ME-5 to the Contribution Accounts Management Department for payors within the
NCR or to Service Offices/PhilHealth Regional Offices (PROs) for payors outside NCR. The Duplicate Copy of this form
shall be the Payor's Copy. Deadline of payment of contributions shall be on the 10th day of the month following the
applicable month. Employers who fail to comply with the above requirements shall be subjected to the penalties provided
under Article X, R.A. 7875. Please submit this report every quarter ending only.

Box 5: Always indicate the applicable quarter and year, of premium contributions paid by checking the box opposite the applicable quarter COPY DISTRIBUTION SUBMISSION OF FORMS
ending. The month coverage in the RF-1 should correspond with the month coverage indicated in the ME-5. Eg., Ms. D remitted P375 for Form No. of 1st 2nd 3rd 4th Appicable Quarter Deadline of Submission
premium due for January 2000, P375 for February 2000, and P375 for March 2000, check the box opposite the quarter ending March and RF-1 Copie
2 PHIC Payor X X January - March April 15
indicate the amount of contribution for each column (i.e., amount remitted for January in the 1st Month; February for the 2nd month & March ME-5 s4 Payor PHIC PHIC Bank April - June July 15
for the 3rd Month) in Box 9. July - September October 15
October - November January 15
Box 6: Print the names of Employees/Househelpers in Alphabetical order, surname first. Write Family Names as they are pronounced. For
instance, the names JULIAN DELA CRUZ, LILIA DELOS SANTOS and MARIA DE GUIA should be written as DELA CRUZ, JULIAN;
DELOS SANTOS, LILIA and DE GUIA, MARIA. Also, names with suffixes such as Jr., Sr., III, etc. should always be written after the family
name. Do not skip lines when listing down their names. Write "NOTHING FOLLOWS" on the line immediately following the last listed NHIP MONTHLY PREMIUM CONTRIBUTION SCHEDULE 2005
employee/househelper.
Box 7: Indicate the corresponding PhilHealth Identification No. (PIN) opposite the respective names of your employees/househelpers to MSB Monthly Salary Range Salary Base Total Monthly Personal Share Employer Share
ensure that all contributions paid will be credited to them. IF WITHOUT PIN, INDICATE THEIR SSS/GSIS NO. (SB) Contribution (PS) (ES)
1 P 4,999.99 and below P4,000.00 P 100.00 P 50.00 P 50.00
2 5,000.00 to 5,999.99 5,000.00 125.00 62.50 62.50
3 6,000.00 to 6,999.99 6,000.00 150.00 75.00 75.00
Box 8: The monthly premium contribution of an employee is based on his actual monthly compensation. Write your employees' respective 4 7,000.00 to 7,999.99 7,000.00 175.00 87.50 87.50
Monthly Compensation Bracket according to their actual monthly compensation for the given quarter. The monthly compensation bracket, is 5 8,000.00 to 8,999.99 8,000.00 200.00 100.00 100.00
determined by the monthly salary range, the employee's actual monthly compensation belongs. Please refer to the Revised NHIP Monthly 6 9,000.00 to 9,999.99 9,000.00 225.00 112.50 112.50
Contribution Schedule. Ex., Ms. R received P4,350.00 for October 2000, P4,750 for November 2000 and P4,350.00 for December 2000 so 7 10,000.00 to 10,999.99 10,000.00 250.00 125.00 125.00
her compensation for the 1st month (October) falls in bracket 3, falls in bracket 4 for Novemberand falls in bracket 3 for December. 8 11,000.00 to 11,999.99 11,000.00 275.00 137.50 137.50
9 12,000.00 to 12,999.99 12,000.00 300.00 150.00 150.00
10 13,000.00 to 13,999.99 13,000.00 325.00 162.50 162.50
Box 9: Indicate corresponding Personal Share (PS) and Employer Share (ES) on the boxes provided per monthly remittance . The total 11 14,000.00 to 14,999.99 14,000.00 350.00 175.00 175.00
premium contribution (PS + ES) for each month must fall within the prescribe salary bracket. Ex. If Ms J's monthly compensation bracket for 12 15,000.00 to 15,999.99 15,000.00 375.00 187.50 187.50
the months of October, November and December are 4, 4, and 5 respectively, her Personal Share (PS) for October should be P56.25, 13 16,000.00 to 16,999.99 16,000.00 400.00 200.00 200.00
P56.25 for November and 62.50 for December.The Employer Share (ES) shall also be P56.25 for October, P56.25 for November and 14 17,000.00 to 17,999.99 17,000.00 425.00 212.50 212.50
P62.50 for December. 15 18,000.00 to 18,999.00 18,000.00 450.00 225.00 225.00
16 19,000.00 to 19,999,99 19,000.00 475.00 237.50 237.50
Box 10: In the "REMARKS" column indicate "S" if employee is separated, "NE" if with no earnings and "NH" if employee is newly hired 17 20,000.00 and up 20,000.00 500.00 250.00 250.00
including date of separation, period/date when the employee had no earnings and date of hiring respectively.

Box 11: Supply needed information on the "ME-5 Summary of Contribution Payments". Indicate the corresponding ME-5 Reconciliation THIS FORM MAY BE REPRODUCED
No., found in the lower left portion of the ME-5 form, for each month. Total monthly premium to be indicated opposite the applicable month
coverage in the ME-5 should also tally with the amount reflected in the RF-1.

Box 12: Add all contributions in the personal share (PS) column and employer share (ES) column, for each month and reflect the sum in
the "Subtotal" box for each page. Consequently, add all Subtotals/Page totals and reflect sum in the "Grand Total" box in the last sheet of
the accomplished RF-1 to indicate total amount of contributions paid for the applicable quarter.