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NAME OF BORROWER FAMILY NAME PARTICULARS FIRST NAME MIDDLE NAME PERAA I.D. NO. MONTHLY AMORTIZATION PENALTY (IF ANY) REMARKS TOTAL APPLICABLE NO. OF MONTHLY AMORTIZATIONS Indicate Date and N - if new member R - Resigned L - on leave Change name (e.g. married name) TOTAL: PERAA USE ONLY FORM OF REMITTANCE CERTIFIED CORRECT BY: Bank Remittance with 1st entry : Date Signature: Date Printed Name: 2nd entry: Check (Enclosed) Matched : Money Order (Enclosed) Official Title: Ca.

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