CLIENT'S COPY TO OUR VALUED CUSTOMER: Before leaving the Teller’s Counter, please verify the correctness of the NAME, ACCOUNT NUMBER or REFERENCE NUMBER, AMOUNT, and other deposit / payment details on the Teller’s Validation below based on your input in our Customer Transaction Assistant Machine. Member of the Philippine Deposit Insurance Corporation Maximum Deposit Insurance for Each Depositor Php 500,000.00 THANK YOU FOR BANKING WITH US [_THANKYOUFOR BANKING WTHUS_| This deposit / payment is subject to the Terms and Conditions covering this account. TELLER’S VALIDATION (THIS IS YOUR RECEIPT WHEN MACHINE VALIDATED.) 92 100CT17_ DEPOSIT 3567 IMU2 Nes 004429-0584-44 PHP™ % #9 OOES OO CHECKS 945.00 ONUS 945.00 09:51:03 JANDALE A GALLARDO _~_] ee ne‘ AVENTUS MEDICAL CARE.INC. Room 301 3rd Fir Comfoods Bldg Sen. Gil Puyat corner Chino Roces Ave. Makati City PAYEE JANDALE GALLARDO PESOS : Nine Hundred Forty-Five Pesos and 00/100 only REMARKS :PAYMENT FOR PROFESSIONAL FEE (RELIEVER DOCTOR) CLINIC MGT. DUTY AT ALORICA MADRIGAL DATED SEPTEMBER 21, 2017. (PRF-10026) Particulars Accounts payable - Trade Cash in Bank - BPI 1 (CASA Acct No 3561-0302-34) Preparad by: NIKKA MAE\LAPUZ Account No. 3561030234 DATE : October 5, 2017 P 945.00 Voucher No 93869 Check Number 1298854 Bank BPI Location Debit Credit 945.00 Clinic Management 945.00 Received by: eee oantiGe eoira ee Signature of Payee / Date Approved b JOHNNA A. ARCOYO Y- wlKogoreret Primeda Certificate of Creditable Tax a 307 Kawanihan ng Rentas Internas With held At Sou rce eo. Identification Number 3. Payee's Name Individuals) 4 Registered Address : ” a 4A Zip Code Co | > 5 Foreign Address Payor Information 6 Taxpayer Identification Number -[o,0,7] [2,40] [5,1,6] [0.0.0] 7 Payors Name »| AVENTUS MEDICAL CARE, INC. (Last Name, First Name, Middle Name for Individuals) (Registered Name for Non-Individuals) 8 Registered Address §| Room 301 3rd Floor Comfoods Bldg. Sen. Gil Puyat Avenue Cor. Chino Roces, MpkeAiZip Code . [| Details of Monthly Income Payments and Tax Withheld for the Quarter Income Payments Subject to ae AMOUNT OF INCOME PAYMENTS. Tax Withheld 1st Month of 2nd Month of 3rd Month of Expanded Withholding Tax tie Quader ane Quarter the Quarter For the Quarter Medical Services WHS sai) Cau 1,050.00 met oo ae £3 We declare, under thé pursuant to the provisions of, ational Internal Revenue Code, as amended, and the regulations issued under authority thereof. INATHAN GIMENEZ 253-852-650-000 Payor/Payor’s Authorized Representative/Accredited Tax Agent TIN of Signatory (Signature Over Printed Name) IConforme: Payee/Payee’s Authorized Representative/Accredited Tax Agent TIN of Signatory Title/Position of Signatory Date Signed (Signature Over Printed Name)