File name : R303****************2.

04062003

Employer name: Juana Dela Cruz Date: Apr 11, 2017

Employer No : 03-9****34-6 App. Period:

PAYMENT INFORMATION

TR/SBR NUMBER : 286******20

DATE OF PAYMENT : [state the date of payment]

AMOUNT PAID : [state the amount]

ENCODED INFORMATION

SS AMOUNT : .00

EC AMOUNT : .00

TOTAL AMOUNT : .00

Total number of Employees:

CERTIFIED CORRECT AND PAID

RECEIVED BY : _____________________________

DATE RECEIVED : _____________________________

TRANSACTION NO: _____________________________