MONTHLY SALARY SETTLEMENT

WORKER'S DATA

RUT:

NAME:

Compensation Period Month: Year:

REMUNERATION BREAKDOWN
Worker's Salaries Value

Base Salary $
Other Taxable Income $
Total Taxable Compensation $0

Mobilization $
Collation $
Per diem $
Expense Reimbursement $

Total assets (1) $0

Discounts Value
Pension Contribution (AFP or INP) AFP ___________ _____ $ ( )

Health Quotation (Fonasa or Isapre) $( )

Voluntary Contribution and AFP Savings Account $( )

Total Social Security Discounts $( 0 )

Other Discounts $( )

Total Discounts (2) $( 0 )

CASH (1) - (2) $ Advances or loans $ ( 0 )

NET BALANCE PAYABLE $ 0

I certify that I have received from my Employer Mr. (a) : ____________________________________________________,

to my total and entire satisfaction the liquid balance indicated in the present settlement, without having any subsequent charge or
collection to make, for the concepts of this settlement.

Date: __________________________________

Worker's Signature