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RS-5 2008

This document is a contributions payment return form submitted to the Social Security System of the Philippines. It contains personal information of Moises Santos such as his social security number, address, and contact details. The form shows his social security contributions for January 2012 amounting to 1,560 Philippine pesos. It requires his signature to certify the accuracy of the payment details.

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Gee Mitchy
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151 views1 page

RS-5 2008

This document is a contributions payment return form submitted to the Social Security System of the Philippines. It contains personal information of Moises Santos such as his social security number, address, and contact details. The form shows his social security contributions for January 2012 amounting to 1,560 Philippine pesos. It requires his signature to certify the accuracy of the payment details.

Uploaded by

Gee Mitchy
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Republic of the Philippines

SBR NO.

POST MARK/SBR DATE

TELLER'S INITIALS

RS-5
REV. 06-04

SOCIAL SECURITY SYSTEM

CONTRIBUTIONS PAYMENT RETURN


(TO BE SUBMITTED IN TRIPLICATE)
(SURNAME)

AMOUNT DATE (THIS IS YOUR OFFICIAL RECEIPT WHEN VALIDATED) (GIVEN NAME) (MIDDLE NAME)

SS NUMBER

0 5 2

6 7

5 5 5

SANTOS

MOISES
(BARANGAY)

MI-OT
POSTAL CODE

USUAL ADDRESS IN THE PHILS.:

(NO. & STREET)

313 G AGLIPAY ST MANDAUYONG CITY


(TOWN/DISTRICT) (CITY/PROVINCE) TEL. NO./CELL NO.

09329446576

INSTRUCTIONS
1. CHECK THE BOX TO INDICATE THE TYPE OF PAYOR: SELF-EMPLOYED VOLUNTARY NON-WORKING SPOUSE FARMER/FISHERMAN ____________

OVERSEAS WORKER (Foreign Address - City, Country) _______________________ _____________________________________________________________________ 2. REMIT YOUR CONTRIBUTIONS ON OR BEFORE THE 10TH DAY OF THE MONTH FOLLOWING THE APPLICABLE MONTH OR QUARTER AT ANY SSS ACCREDITED BANK OR SSS OFFICE ACCEPTING PAYMENTS OR THROUGH REGISTERED MAIL. IF THE 10TH DAY FALLS ON A SATURDAY, SUNDAY OR HOLIDAY, THE DEADLINE SHALL BE ON THE NEXT WORKING DAY. 3. ACCOMPLISH THE DECLARATION OF EARNINGS BELOW IF YOU DESIRE TO CHANGE YOUR MONTHLY SALARY CREDIT (MSC) TO MORE THAN TWO SALARY BRACKETS OR IF THE CHANGE WILL RESULT TO AN MSC OF LOWER THAN P 5,000. I hereby declare, for purposes of Sec. 19-A of the Social Security Law, the amount of ______________________________________________________________________ (P ____________ ) as my monthly earnings, which shall be the basis of my monthly salary credit to be effective until revised in my next declaration. 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. ______________________ SIGNATURE OF MEMBER

Applicable Period Month Year JANUARY 2012 FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER
Penalty (Ref. No. _________)

Social Security Contribution

1,560.00

TOTAL REMITTANCE
TOTAL AMOUNT IN WORDS:

P 1,560.00

ONE THOUSAND FIVE HUNDRED SIXTY PESOS ONLY


CERTIFIED CORRECT:

SIGNATURE OVER PRINTED NAME DETAILS OF CHECK PAYMENT: AMOUNT: P ___________________________ BANK NAME:___________________________ CHECK NO.: _______________________ DATE: ____________________________

MOISES M. SANTOS

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