TO : ALL CONCERNED
FROM : HRAD DEPARTMENT
DATE : _____________________________
Employee Name : ___________________ ACTION TAKEN:
Div/Department : ___________________ ______Clearance
Position : ___________________ ______Hold Clearance
Date Hired : ___________________ ______Others
Date of Resignation : ___________________
Effective Date of Resignation: ___________________
1. Receivables (Salary, Allowance, etc.) P _____________
_____________
_____________
_____________
Sub Total _____________
2. Less: Deductions
________________ ______________
________________ ______________
Sub Total ______________
3. Net Amount due P______________
Note: Paymaster shall not release any amount due until personnel manager sign final approval of employee’s
clearance.
Please indicate any account/tool/office equipment/etc. to be settled/returned by the employee.
Division/Department Authorized Signatory Signature Date
1. Dept/Div. Head: ________________________ __________ _________
2. Asset Management __________________ ___________ _________
3. Human Resources __________________ ___________ _________
4. Accounting __________________ ___________ _________
This is to authorize the company to deduct from any accrued wages, emoluments, gratuities, or any other kind
of compensation due to me from the above company any outstanding obligation or debt as maybe reflected
above.
________________________
Employee’s Signature over printed name-date