To be filled up by BIR DLN:

390 662 081 0000

Fill in all applicable white spaces. Mark all appropriate boxes with an 'X'.
1 Taxpayer Type X Local Employee 2 Date of Registration 03/31/2021 3 RDO Code 042
Resident Alien Employee
Part I Taxpayer / Employee Information
4 TIN Sex Male 6 Citizenship
X FILIPINO
(For Taxpayer w/ existing TIN) Female
7 Taxpayer's Name 8 Date of Birth
LEONEN, ALEAH MAE SALCEDO 08/21/1996

9 Local Residence Address 10 Telephone No.

ZONE 1 YAKAL ST SANTIAGO 09193365189

, CAMARINES SUR 4400

11 Zip Code 12 Municipality Code
13 Foreign Residence Address

14 Tax Type Form Type ATC

Income Tax X BIR Form 1700 - (For Individual Earning Compensation Income/Resident Alien Employee) II 011
Part II Personal Exemptions
15 Civil Status 16 Employment Status of Spouse:
X Single Widow/Widower Unemployed
Legally separated Married Employed Locally
Employed Abroad
with qualified dependent child/ren X without qualified dependent child/ren Engaged in Business/Practice of Profession

17 Claims for Additional Exemptions/Premium Deductions for husband and wife whose aggregate family income does not exceed P250,000 per annum
Husband claims additional exemption and any premium deduction Wife claims additional exemption and any premium deduction
18 Spouse Information (Attach Waiver of Husband)
Spouse Taxpayer Identification Number Spouse Name
18A 18B

Last Name First Name Middle Name

18C Spouse Employer's Taxpayer Identification Number 18D Spouse Employer's Name

Part III Additional Exemptions

19 Names of Qualified Dependent Child/ren (refers to a legitimate, illegitimate, or legally adopted child chiefly dependent upon & living with the taxpayer; not
more than 21 years of age, unmarried, and not gainfully employed; or regardless of age, is incapable of self-
support due to mental or physical defect).
Mark if Mentally
Last Name First Name Middle Name Date of Birth / Physically
( MM / DD / YYYY ) Incapacitated

19A 19B 19C 19D 19E

20A 20B 20C 20D 20E

21A 21B 21C 21D 21E

22A 22B 22C 22D 22E

Part IV For Employee With Two or More Employers (Multiple Employments) Within the Calendar Year
23 Type of multiple employments
Successive employments (With previous employer(s) within the calendar year)
Concurrent employments (With two or more employers at the same time within the calendar year)
[If successive, enter previous employer(s); if concurrent, enter secondary employer(s)]
Previous and Concurrent Employments During the Calendar Year
TIN Name of Employer/s

24 Declaration
I declare, under the penalties of perjury, that this form has been made in good faith, verified by me and to the best of my knowledge and belief,
is true and correct, pursuant to the provisions of the National Internal Revenue Code, as amended, and the regulations issued under authority thereof.

TAXPAYER (EMPLOYEE) / AUTHORIZED AGENT

(Signature over printed name)
Part V Employer Information
25 Type of Registered Office X HEAD OFFICE BRANCH OFFICE
26 Taxpayer Identification Number 000057225 27 RDO Code 042
(To be filled up by BIR)
28 Employer's Name (Last Name, First Name, Middle Name, if Individual/ Registered Name, if Non-Individual)
LIVAN TRADE CORPORATION

29 Employer's Business VALLEYGOLD TOWNHOUSE # 612 PINAGLABANAN PEDRO CRUZ SAN JUAN CITY
Address
30 Zip Code 31 Municipality Code 33 Effectivity Date 34 Date of Certification
1500 (To be filled (Date when Exemption Information is applied) (Date of Certification of the Accuracy of the
up by the BIR) 03/31/2021 Exemption Information) 03/31/2021
32 Telephone Number 7270551

35 Declaration Stamp of BIR Receiving Office

I declare, under the penalties of perjury, that this form has been made in good faith, verified by and Date of Receipt
me and to the best of my knowledge and belief, is true and correct, pursuant to the provisions of the
National Internal Revenue Code, as amended, and the regulations issued under authority thereof.

Attachments Complete?
EMPLOYER / AUTHORIZED AGENT Title / Position of Signatory (To be filled up by BIR)
(Signature over printed Name) Yes No

ATTACHMENTS: (Photocopy only)

For Individuals Earning Purely Compensation Income
- Birth Certificate or any valid identification card of applicant showing complete name, address, birth date and signature (Driver's license, PRC ID or passport)
- Marriage Contract, if applcable
- Waiver of husband to claim additional exemption , if applicable
- Birth Certificate/s of dependent/s, if applicable
- Employment Certificate or valid company ID with picture and signature, if available
POSSESSION OF MORE THAN ONE TAXPAYER IDENTIFICATION NUMBER (TIN) IS CRIMINALLY PUNISHABLE PURSUANT
TO THE PROVISIONS OF THE NATIONAL INTERNAL REVENUE CODE OF 1997, AS AMENDED.
 Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

Corporate Action Center Hotline - (02) 441-7442
www.philhealth.gov.ph

MEMBER DATA RECORD

MEMBER BASIC INFORMATION
PhilHealth Identification Number (PIN) : 01-026561971-7 PhilSys Number :
Member Category : FORMAL ECONOMY - PRIVATE -
Sub-Category PERMANENT/REGULAR NHTS Coverage : N/A
Validity Period : N/A - N/A

LEONEN, ALEAH MAE SALCEDO

ZONE 1 YAKAL STREET SANTIAGO, IRIGA CITY CAMARINES SUR

Foreign Address : N/A Sex : FEMALE

Date of Birth : 08/21/1996
Place of Birth : QUEZON CITY, SECOND
DISTRICT
Contact No. (Foreign) : N/A Civil Status : SINGLE
(Local) : +639193365189 Tax Identification Number :

ENTITY INFORMATION
PhilHealth Number (PEN/POGN) : 20-057430010-3
Name of Employer/Organized Group : LIVAN TRADE CORPORATION
hidden text
Business Address : VALLEYGOLD TOWNHOUSE 612 PINAGLABANAN ST, null, SAN JUAN SECOND DISTRICT
hidden text
Telephone Number : 7270551 Employment Status : EMPLOYED
Tax Identification Number : 042000057225 Date : 01/20/2020

DEPENDENT INFORMATION
PIN Surname Given Name Middle Name Sex Relation Date of Birth
*** NOTHING FOLLOWS ***

HENRY V. ALMANON
REGIONAL VICE PRESIDENT
Philhealth Regional Office - V Legaspi City

Paalala: Basahin ang nilalaman ng MDR. Kung may kulang o mali, ibalik agad upang maiwasto. Ingatan ang orihinal na kopya at huwag ibigay kahit kanino. Kung
sakaling gagamit at makikinabang ng benepisyo, magbigay ng kopya sa ospital. (Reminder: Read the contents of the MDR. Should there be any data discrepancies,
return it back to amend or rectify the error. Take good care of MDR and do not hand it over to anybody. Provide photocopy to hospital in case of confinement and
availment of benefits.)
This is a Member Portal System generated report. Signature is not required.
Apr 14, 2021 12:36 PM