CQN-01181 (05-2014)

(THIS IS YOUR OFFICIAL RECEIPT WHEN VALIDATED)

PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT

THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE
BLAC•{ INK ONLY.

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

D Self-Employed D Non-Working Spouse
D Business D Household CJ Voluntary D Farmer/Fisherman
OFW (Foreign Address· City, Country
EMPLOYER NUMBER ss NUMBER (10DIGITS) COMMON REFERENCE NUMBER (IF ANY. 12 OIGffS)
03-926031
EMPLOYER NAME NAME
Primoris Manpower services Company
TO BE FILLED OUT BY EMPLOYER AND INDIVIDUAL PAYOR
DDRESS (RM./FLR./UNIT NO. & BLOG. NAME) (HOUSE/LOT & BLK. NO.) (STREET NAME) (SUBDIVISION) (BARANGAYIDISTRICT/LOCALITY)
Unit Alabang Citi Arcade Bldg., Cupang Muntinlupa
(CITY/MUNICIPALITY) (PROVINCE) ZIP CODE TAX IDENTIFICATION NUMBER (IF ANY)
1 1 I 007-993-053-000
TELEPHONE NUMBER (AREACODE+TEL. NO.) MOBILE/CELLPHONE NUMBER E-MAIL ADDRESS WEBSITE (FOR BUSINESS EMPLOYER)
846-06-84
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 PAYORl EMPLOYER ONL_"2 EMPLOYER ONLYl
January .p .p
February
March
April
May
June
July
August
September
October
November
December 2018 I 9.020.00 694,760.00
.p .p.

685,740.00 � 9,020.00 .p 694,760 00

p
AMOUNT PAID IN FIGURES TOTAL AMOUNT PAID IN WORDS
.p
Six Hundred Ninety Four
Thousand Seven Hundred Sixty
Pesos & 00/100
Check Number PAID BY
Check Date 01-23-2019
Bank & Branch Name -------
BPI- Mario D. Raymundo
TOTAL AMOUNT PAID P. 694,760.00 PRINTED NAME
DECLARATION OF EARNINGS OF INDIVIDUAL PAYOR
I hereby declare, for purposes of Sec. 19-A of the Social Security Law the amount of---------,;''-- ----------
(fl ______, as my monthly earnings, which shall be the basis of my monthly salary credit to be effective untii revisfd in my next dec!aration.
I affirm under the penalties of perjury, that this declaration has been made in good faith, and to the best of my knowledge and belief, is true and correct.

PRINTED NAME OF MEMBER SIGNATURE OF MEMBER