NOTARIZED LIST

SURNAME

1 ABRASALDO
2 ASEÑERO
3 DANDOY
4 DELA TORRE
5 EDRIAL
6 HO
7 TABUAY
8 VILLAFLORES
9 VILLAFLORES
10
11
12
13
14
15
16
17
18
19
20

EMPLOYMENT STATU
a. Permanent/Regul
b. Casual
c. Probationary
d. Contractual
e. Apprenticeship

Photocopy of DTI BN Re
Sketch Plan of Office lo
Specimen Signature car
Employer Registration F
SSS R3 (SSS Registration
1 . Fill out this form

2 . Fill out the appr

a. For business em
-

b. For household
-

3 . Always indicate

4 . Always affix initi

5 . Write "NOTHING

6 The owner of a s
he/she is not ov

7 . The signatory in
 HOME DEVELOPMENT MUTUAL FUND
DUMAGUETE MEMBER SERVICES BRANCH
Name of Company
TOLONG SUGARCANE GROWERS, INC. Employer ID/RTN :
Address : URC - TOLONG COMPOUND, CARANOCHE, STA. CATALINA, NEG. OR. Date of registration with : SECURITIES & EXCHANGE COMMISION(SEC)
Tel. Nos. : (035) 531-0024 DEPARTMENT OF TRADE & INDUSTRY(DTI)
D LIST OF ALL EMPLOYEES WITH THEIR CORRESPONDING SALARY SOCIAL SECURITY SYSTEM(SSS)
DATE OPERATIONS STARTED :

DATE Pag-ibig MID SUBJECT TO

ME FIRST NAME MIDDLE NAME HIRED RS. 7742 2010 2011 2012 2013 2014 2015 2016 2017 2018
No. (1995-2009)

DO KATHREEN DIANN CORTEZ 11/18/2017

AMMIE ONTAL 01/2/2018
KEITH DURBIN SAPLOT 11/18/2017
RE RODENILO RITUAL 11/18/2017
WALTER EGE 11/18/2017
KIRA LEEZA RODRIGUEZ 11/18/2017 1210-4095-5420
BEMBO RETANIA 11/18/2017
RES MARIA JONELYN MAMIGO 11/18/2017
RES MARITES LAZARO 11/18/2017

NT STATUS TOTAL NO. OF Ees I declare, under the penalties of perjury that this Authorized Signatory:
nt/Regular notarized list has been made in good faith, verified
by me and to the best of my knowledge and belief
ary is true and correct, pursuant to the provision of Signature over Printed Name
al R.A. 7742 as amended by RA 9679 and the regulations
eship issued under authority, thereof.
Designation

REQUIRED ATTACHMENTS: SUBSCRIBED AND SWORN TO before me this __________ day of ________________________________ 201_____
DTI BN Registration or SEC Registration this City / Municipality _________________________________________ Province of _______________________by
Office location affiant who exhibited to me his/her Res. Cert. No. _______________ issued at _______________on________________.
nature card (3 pieces) FOR QUERIES:
stration Form (online) Contact Marketing & Enforcement Division: Doc. No. NOTARY PUBLIC
egistration) Tel. Nos. (035) 225-7713 / 422-2170 Page No. Until December 31, 20 ____
Book No. PTR No. _____________________
 Series of Issued on : __________________
Issued at: ___________________

INSTRUCTIONS

his form in two (2) copies

he appropriate boxes for the Type of Employer, as follows:

ness employer
correct employer ID number, business name, business address (local and foreign, if applicable), telephone number, mobile/cellphone number, e-mail address,
website, and business Tin as registered with the SSS in Employer Registration Form (SS Form R-1)
sehold employer
correct household employer ID number, household employer name, home address, telephone number, mobile/cellphone number, e-mail address, and personal
TIN, if any, as registered with the SSS in Employer Registration Form (SS Form R-1)

ndicate "N/A" or "Not Applicable", if the required data is not applicable.

ffix initials on erasures on this form.

OTHING FOLLOWS" immediately after the last entry on reported employee.

er of a single proprietorship business is disqualified to be reported as an employee thereof, However, the owner may register as a self-employed member, provided,
not over sixty (60) years old.

atory in this form should be one of the authorized signatories in the current SS Form L-501.

WARNING

MISREPRESENTATION OF THE TRUE DATE OF EMPLOYMENT, MONTHLY EARNINGS, OR OTHER DATA OF EMPLOYEES IS PUNISHABLE UNDER THE PENAL PROVISION
OF THE SS LAW.