Notice on Shipment/Ship-out Processing Fee Payment Slip Form

GLDD Payment Slip Form Reference No.: Page No. Page 1 of 1 SHIPMENT/SHIP-OUT PROCESSING Form No. GLDD - 1202 FEE PAYMENT SLIP FORM Revision No. 2 Effectivity June 15, 2021 Use this form to transmit payment/s for shipment/ship-out processing fee due to PAGCOR relative to the processing of shipment/ship-out of gaming equipment and gaming paraphernalia. Only Shipment/Ship-out Clearance Request 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 Approval Form. SECTION A: PAYMENT INFORMATION / DETAILS (TO BE FILLED UP BY LICENSEE/SUPPLIER) Licensee Supplier Name of Licensee/Supplier: Address: T.I.N. : (to be filled-up by new Licensee/Supplier only) Payment Mode: Cash in the amount of . Check/s with details as follows: Check No. Amount* Date* Name of Bank & Branch* Bank Deposit Name of Landbank Date of Deposit Amount* Branch Branch Code For Bank Deposit please attach a 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 period before an Official Receipt is issued by FTD. 3) In the event that a check is returned by the bank due to insufficient funds or any other reason, the Licensee/Supplier shall settle the arrears in cash or by issuing a Manager’s Check SECTION B: PAYMENT DETAILS (TO BE FILLED UP BY PAGCOR GLDD) Shipment Clearance GLDD Reference no. Commercial Invoice No. Ship-Out Clearance SECTION C: SUBMISSION INSTRUCTIONS Once Section A is completed, please submit this form together with the supporting payment documents as indicated below: For cash/check payments, please proceed to: For deposits to PAGCOR Opex Account, here are the bank details: Gaming Licensing and Development Department Account Name: PAGCOR OPEX Fund Philippine Amusement and Gaming Corporation Account no: C/A No. 3402-1036-70 Landbank Branch: LBP Plaza, Malate, Manila 12th Floor iMET BPO Tower CBP-1A Metropolitan Park Roxas Blvd., Pasay City Note : Please furnish the GLDD with a copy of this form duly received by FTD and a copy of the corresponding Official Receipt (O.R.).  Issuance of O.R. by FTD shall be a pre-requisite for processing of shipment/ship-out clearance.  PAGCOR shall not be held liable for any delay in the processing caused by incomplete submissions.