File name

: R30809462506072013.09080936
Employer name: WELLA JANE D. ATA
Employer No : 08-0946250-6

Date: Sep 08, 2013

App. Period: 07-2013

PAYMENT INFORMATION
TR/SBR NUMBER :
357825 FW
DATE OF PAYMENT :
Aug 07, 2013
AMOUNT PAID
:
966.00
ENCODED INFORMATION
SS AMOUNT
:
EC AMOUNT
:
TOTAL AMOUNT
:

936.00
30.00
966.00

Total number of Employees: 3

CERTIFIED CORRECT AND PAID

RECEIVED BY : _____________________________
DATE RECEIVED : _____________________________
TRANSACTION NO: _____________________________

WELLA JANE D. ATA

Date: Sep 08, 2013

[R30809462506072013.09080936]

FAMILY NAME

GIVEN NAME

MI SS NUMBER

S.S.

CHICANO
LOREJO
QUIZA

ROLANDO
MARILYN
ROMUALDA

L
C
R

312.00 10.00
312.00 10.00
312.00 10.00

Total Number of Employees: 3

WELLA JANE D. ATA

08-0736336-4
08-2218028-9
08-0471017-2

E.C.

RMRK DTHRD
N
N
N

0
0
0