Republic of the Philippines

Department of Education
Region IV-A (CALABARZON)
DIVISION OF CAVITE
Trece Martires City

January 11, 2017

MS. ANN GERALYN T. PELIAS

Chief Administrative Officer
Department of Education RO IV-A
Gate 2 Karangalan Village
Cainta, Rizal

Sir / Madam:

Please adjust this deduction(s) being affected from my monthly salary effective
____________ as indicated hereunder:
( Payroll Month - Year)

DISCONTINUE/
STOP __________________________________
( Name of Insurance Company Code No.)

________________
( Amount of Deduction)

DEDUCT ___________________________________________
( Name of Loan / Insurance Company Code No.)

__________________________________________
( Amount of Deduction)

ADJUST _________________________________________
( Name of Loan / Insurance Company Code No.)

__________________________________________
( Amount of Deduction)

From : _______________________________

To: _______________________________

Very truly yours,

Name of Teacher/ Employee :

Division :
Station:
Employee No.