Republic of the Philippines PAYOR's COPY

SOCIAL SECURITY SYSTEM

CONTRIBUTIONS
coN-0118'1 (05-2014) PAYMENT FORM
(THIS IS YOUR OFFICIAL RECE]PT WHEN VALIDATED)

PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT

THIS FoRI\I. PRINT ALL INFoRMATIoN IN CAPITAL LETTERS AND USE
BLACK INK ONLY.

TO BE FILLED OUT BY EMPLOYER TO BE FILLED OUT BY INDIVIDUAL PAYOR

tr Self-Employed D Non-Working Spouse
E Business fl Household tr Voluntary f] Farmer/Fisherman
tr OFW (Foreign Address - Cily, Country )
EMPLOYER NUMBER SS NUMBER qro orcrsl COIVMON REFERENCE NUMBER (rFANy 12DGrrs)

EMPLOYER NAME \AME T

TO BE FILLED OUT BY EMPLOYER AND INDIVIDUAL PAYOR

ADDRESS (RM-/FLR/UNIT NO & BLDG, NAME) (HOUSE/IOT & BLK, NO,) (STREET NAME) (SUBDIVISION) (BARANGAY/DISTRJCT/LOCAL]TY)

(CITY/MUNTCTPAL|TY) (PROVINCE) ZIP CODE TAX IDENTIFICATION NUMBER rrreryr

TELEPHONE NUIVBER (AREA-coDE+rEL No ) MOBILE/CELLPHONE NUMBER E-MAIL ADDRESS WEBSITE (FoR BUSTNESS EMpLoyER)

PAYMENT DETAILS
APPLICABLE PERIOD SS CONTRIBUTION EC CONTRIBUTION TOTAL
(TO BE FILLED OUT BY EMPLOYER & INDIVIDUAL (TO BE FILLED OUT BY (TO BE FILLED OUT BY
MONTH YEAR PAYOR) EMPLOYER ONLY) EI\,4PLOYER ONLY)
January P P F
February
l\,4 a rch

April
May
June
July
August

September
October
November
Decem ber

A Penalty P F
D
F
D Underpayment
SUB-TOTAL F P F
TOTAL AMOUNT OF PAYMENT P
F9RM oF PAYMENT AMOUNT PAID IN FIGURES TOTAL AMOUNT PAID IN WORDS
n casir p
I Postat lVoney Order
E crrect<
Check Number PAID BY
Check Date
Bank & Branch Name
TOTAL AMOUNT PAID F PRINTED NAME SIGNATURE
DECLARATION OF EARNINGS OF INDIVIDUAL PAYOR
I hereby declare, for purposes of Sec. 19-A of the Social Security Law the amount of
(F=*--) as my monthly earnings, which shall be lhe basis of my monthly salary credit to be effective until revised in my next declaration.
I afflrm under the penalties of perjury. that this declaration has been made in good faith, and to the best of my knowiedge and belief, is true and
correct.

PRINTED NAME OF IVEMBER SIGNATURE OF I\,lEMBER