1.22 REMITTANCE PAYMENT PROCESSING REQUEST FORM

Page No. Page 1 of 1 REMITTANCE PAYMENT PROCESSING Form No. EGLD - 434 REQUEST FORM Rev. No. 3 Effectivity August 17, 2023 GS Form No. 29 CMED Reference No.: _________________ Use this form to transmit payment/s from the Service Provider representing income share/s, fees, and/or any amount due to PAGCOR. Only request forms with correct and complete information and supporting documents will be processed. Failure to provide correct and complete information could result in non-processing of this request. SECTION A: PAYMENT INFORMATION / DETAILS (TO BE PROVIDED BY SERVICE PROVIDER) Name of Service Provider/Operator: __________________________________________________________________ TIN of Service Provider/Operator: __________________________________________________________________ Name of PAGCOR-approved Project/s: __________________________________________________________________ Nature of Remittance:  Daily Remittance  Adjustment/s  Weekly Remittance  Others __________  Monthly Remittance Payment Mode:  Cash  Check/s  Deposit/s made to PAGCOR OPEX Account Check Details: Check No. Amount* Date* Name of Bank& Branch* . Note: 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 Operator shall settle the arrears in cash or by issuing a Manager’s Check. Payment Details Period Covered PAGCOR Share Regulator’s Fee Others Sub-totals Grand TOTAL By: ____________________________________________ Date: ____________________________________ (signature over printed name) (Please use separate sheet if necessary) SECTION B: SUBMISSION INSTRUCTIONS Once Section A and Section B are completed, please submit this form together with supporting payment documents as indicated below: Note : Please furnish CMED a copy of this form duly received by FMD and copy of the corresponding Official Receipt in the address indicated above. For cash/check payments, please proceed to: For deposits made to PAGCOR Opex Acct, please proceed to: Compliance Monitoring and Enforcement Department Finance Management Department Philippine Amusement and Gaming Corporation Corporate New World Manila Bay Office PAGCOR Main Corporate Office, 12th Floor, iMET BPO Tower, 6th Floor New World Manila Bay Hotel CBP-1A Metropolitan Park, Roxas Boulevard, Pasay City 1588 M.H. del Pilar corner Pedro Gil Sts., Malate, Manila Tel. Nos. (+632) 8522‐0299 / 1357/ 1245 / 1324 loc 5128 / 5125 Tel. Nos. 242-0121 loc. 604 And, e-mail within twenty four (24) hours to: [email protected]