HQP-SLF-017

SHORT-TERM LOAN Pag-IBIG EMPLOYER'S ID NUMBER

REMITTANCE FORM ( STLRF )

NOTE: PLEASE READ INSTRUCTIONS AT THE BACK
EMPLOYER/BUSINESS NAME

EMPLOYER/BUSINESS ADDRESS PERIOD COVERED

Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No Street name

Subdivision Barangay Municipality/City Province/State/Country (if abroad) ZIP Code TELEPHONE NUMBER

Pag-IBIG APPLICATION NO. NAME OF MEMBERS LOAN TYPE

MID No. Last Name First Name Name Extension Middle Name
(Jr., III, etc.) (e.g., MPL, Calamity Loan) AMOUNT

TOTAL FOR THIS PAGE

GRAND TOTAL (if last page)
EMPLOYER CERTIFICATION
I hereby certify under pain of perjury that the information given and all statements made herein are true and correct to the best of my knowledge and belief. I further
certify that my signature appearing herein is genuine and authentic.

HEAD OF OFFICE OR AUTHORIZED REPRESENTATIVE DESIGNATION/POSITION DATE

(Signature Over Printed Name)

THIS FORM MAY BE REPRODUCED. NOT FOR SALE (V02, 10/2016)

QP-SLF-017

VERED

E NUMBER

EMPLOYER

REMARKS

DATE

V02, 10/2016)