SHIPMENT/SHIP-OUT PROCESSING FEE PAYMENT SLIP

Page No. Page 1 of 1 SHIPMENT/SHIP-OUT PROCESSING FEE Form No. EGLD - 1613 PAYMENT SLIP FORM Rev. No. 2 Effectivity August 17, 2023 Reference No.: Use this form to endorse and transmit payment/s for shipment/ship-out processing fee due to PAGCOR for the processing of the shipment/ship-out of gaming equipment. Only shipment/ship-out clearance request and approval form with correct and complete information and supporting documents will be processed. Failure to provide correct and complete information could result in non-processing of the said shipment/ship-out request. One Shipment/Ship-out Processing Fee Payment Slip Form per approved Shipment/Ship-out Clearance Request and Approval Form SECTION A: PAYMENT INFORMATION / DETAILS (TO BE FILLED UP BY OPERATOR/SERVICE PROVIDER) Name of Operator/Service Provider: ________________________________________________ Site Address (Office address for Service Provider): ______________________________________ T.I.N. : (to be filled-up by new Operator/Service Provider only): ____________________ Game Offerings: ______ Bingo Games ______ Sports Betting ______ Electronic Games ______ Betting Exchange Payment Mode:  Cash in the amount of .  Check/s with details as follows: Name of Bank & Check No. Amount* Date* Branch*  Bank Deposit Name of Landbank Date of Deposit Amount* Branch Branch Code For Bank Deposit please attach copy of bank validated deposit slip. 1) *Please fill up also for deposits made to PAGCOR OPEX Account. 2) It is understood that Check payments shall be subject to three (3) days clearing before issuance of an Official Receipt. 3) In the event that a check is returned by the bank due to insufficient funds or any other reason, the Licensee shall settle the arrears in cash or by issuing a Manager’s Check. SECTION B: PAYMENT DETAILS  Shipment Clearance Reference no. Commercial Invoice No.  Ship-Out Clearance SECTION C: SUBMISSION INSTRUCTIONS Once Section A is completed, please submit this form together with supporting payment documents as indicated below: For cash/check payments, please proceed to: For deposits to PAGCOR Opex Account, here are the bank details: Finance Group – Banking Division (PAGCOR Cashier) Account Name: PAGCOR OPEX Fund Philippine Amusement and Gaming Corporation Account no: C/A No. 3402-1036-70 6/F New World Manila Bay Hotel, 1588 M.H Del Pilar Landbank Branch: LBP Plaza, Malate, Manila Cor. Pedro Gil St., Malate, Manila  Issuance of O.R. by FTD shall be a pre-requisite  PAGCOR shall not be held liable for any delay in the processing for processing of shipment/ship-out clearance. caused by incomplete submissions.