File name

: R30809462506082013.10021239
Employer name: WELLA JANE D. ATA
Employer No : 08-0946250-6

Date: Oct 02, 2013

App. Period: 08-2013

PAYMENT INFORMATION
TR/SBR NUMBER :
357956 FW
DATE OF PAYMENT :
Sep 10, 2013
AMOUNT PAID
:
1,288.00
ENCODED INFORMATION
SS AMOUNT
:
EC AMOUNT
:
TOTAL AMOUNT
:

1,248.00
40.00
1,288.00

Total number of Employees: 4

CERTIFIED CORRECT AND PAID

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

WELLA JANE D. ATA

Date: Oct 02, 2013

[R30809462506082013.10021239]

FAMILY NAME

GIVEN NAME

MI SS NUMBER

S.S.

E.C.

ATA
CHICANO
LOREJO
QUIZA

WILLY JOHN
ROLANDO
MARILYN
ROMUALDA

D
L
C
R

312.00
312.00
312.00
312.00

10.00
10.00
10.00
10.00

Total Number of Employees: 4

WELLA JANE D. ATA

08-2392895-8
08-0736336-4
08-2218028-9
08-0471017-2

RMRK DTHRD
N
N
N
N

0
0
0
0