ATD/PN/DS No._________
THE HEAD, REGIONAL PAYROLL SERVICES UNIT
DepEd, Regional Office No._________
Address: ____________________________________
AUTHORITY TO DEDUCT
I hereby authorize you to deduct from my salary the sum of ____________________________ (P_____________) for
___ consecutive months beginning ______________________ and to remit the said amount to the PHILIPPINE PUBLIC
SCHOOL TEACHERS ASSOCIATION (PPSTA) in consideration of my loan in the principal amount of
____________________ (P_____________) plus add-on interest and other charges, which was granted to me on
_______________________.
This authorization is VALID AND BINDING until my aforementioned loan is fully paid for or upon written notice of
its discontinuance by the PPSTA.
PROMISSORY NOTE
For value received, the undersigned promises to pay to the order of the PHILIPPINE PUBLIC SCHOOL TEACHERS
ASSOCIATION at its office located at 245 Banawe St. Quezon City, Philippines, through APDS, the sum of PESOS
______________________________ (P_______________) with interest rate of ___________ percent (___%) per annum, TO
BE PAID IN EQUAL MONTHLY INSTALLMENTS IN THE AMOUNT OF P _____________ FOR ________
MONTHS, BEGINNING _____________________ AND ENDING _________________.
Default in the payment for six (6) consecutive installments shall render the entire unpaid balance due and demandable.
IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ___________________ at
___________________.
___________________________________________
(Signature Over Printed name of Borrower)
Employee No._________ Division No.____ Station No.____
School or Station Address____________________________
_________________________________________________
Home Address: ____________________________________
_________________________________________________
CTC No.
Date Issued
Place Issued
Telephone No.:
ACKNOWLEDGMENT
REPUBLIC OF THE PHILIPPINES)
CITY OF _____________________) S.S
X-----------------------------------------)
BEFORE ME, A Notary Public in and for the above jurisdiction, this ___day of __________________ 200___
personally appeared _________________________________ with Community Tax Certificate No. ______________ issued at
_____________________________ on ____________________ known to me and to me known to be the same person who
executed the foregoing instrument and acknowledged to me that the same is his/her free and voluntary act and deed.
WITNESS MY HAND AND NOTARIAL SEAL on the date and place first above-written.
NOTARY PUBLIC
Doc. No.________________
Page No.________________
Book No. _______________
Series of ________________