Department of Education Department of Education

Region IX, Zamboanga Peninsula Region IX, Zamboanga Peninsula

Division of Pagadian City Division of Pagadian City
Pagadian City _________ District Pagadian City _________ District
__________________ SCHOOL __________________ SCHOOL

CLAIM SLIP CLAIM SLIP

Name of Pupil: Name of Pupil:

Grade & Section: Grade & Section:
Teacher: Teacher:

Learning Areas: Remarks/Tick Learning Areas: Remarks/Tick

Mother Tongue Mother Tongue
English English
Mathematics Mathematics
Science Science
Modules Received Modules Received
Filipino Filipino
ARPAN ARPAN
EPP/TLE EPP/TLE
MAPEH MAPEH
EsP EsP

Received by: Received by:

Printed Name and Signature Printed Name and Signature

Relationship: Relationship:
Date: Date:
 Department of Education Department of Education
Region IX, Zamboanga Peninsula Region IX, Zamboanga Peninsula
Division of Pagadian City Division of Pagadian City
Pagadian City _________ District Pagadian City _________ District
__________________ SCHOOL __________________ SCHOOL

ACKNOWLEDGMENT RECEIPT ACKNOWLEDGMENT RECEIPT

Name of Pupil: Name of Pupil:

Grade & Section: Grade & Section:
Name of Parent: Name of Parent:

Learning Areas: Remarks/Tick Learning Areas: Remarks/Tick

Mother Tongue Mother Tongue
English English
Mathematics Mathematics
Submitted Duly Science Submitted Duly Science
Accomplished Self- Accomplished Self-
Learning Modules Filipino Learning Modules Filipino
ARPAN ARPAN
EPP/TLE EPP/TLE
MAPEH MAPEH
EsP EsP

I hereby acknowledged receipt of the modules indicated I hereby acknowledged receipt of the modules indicated
above. above.

Received by: Received by:

Printed Name and Signature of
Printed Name and Signature of Teacher
Teacher

Date: Date: