Republic of the Philippines
NATIONAL POLICE COMMISSION
PHILIPPINE NATIONAL POLICE
REGIONAL FINANCE SERVICE OFFICE 5
Camp BGen Simeon A Ola, Legazpi City
_____________________
Date
FOR : Director, PNPFS
Camp Crame, Quezon City
(Attn: Chief, Salary Assignment Section)
SUBJECT : Salary Assignment
Request that the amount ___________________________________ (P____________)
be assigned to ___________________________________ my
_________________________ (Name of Assignee)
(Relationship to Assignor)
presently residing at
___________________________________________________________
(Address of Assignee) (Contact Nr of the Assignee)
starting ________________________ and monthly thereafter until a request in writing for its
discontinuance is submitted to Finance Service.
It is understood that I will immediately notify the Director of Finance Service thru Salary
Assignment Section of any changes in my status and/or assignment including the address and
contact number of the Assignee from time to time.
The following are the three (3) specimen signatures of the Assignee:
a. ______________________ b. ___________________ c. ___________________
1. The reason(s) for assigning a portion of my salary to my assignee is/are as follows:
_________________________________________________
_________________________________________________
2. I further certify that the foregoing is true and correct.
________________________________
Signature over Printed Name
Unit Code ________________
Account Nr _______________
1st Indorsement
Date: _________________________
Respectfully forwarded to the Director, PNP Finance Service through the Chief, RFSOs
the application for Salary Assignment of _______________________________
(Name of Assignor)
in favor of _____________________________________, _______________________.
(Name of Assignee) (Relationship to Assignor)
I hereby certify that I have processed the application and verified that the Assignee is
the legal wife/dependent of the Assignor.
________________________________
(Name & Signature of Chief of Police)
Unit/Station ___________________
Supporting Documents:
1. Authenticated photocopy of Latest Payslip
2. Photocopy of PNP ID (back to back)
3. Marriage Contract
4. Birth Certificate (NSO)
5. Photocopy of ID of Assignee
6. Endorsement from C, RFSOs
7. Copy of STI 1 or photocopy of LBP ATM Account of Assignee
(Product Type of Account must be 333-for 18y/o & above & 332 for 17y/o & below
