Company Name Nature of business (choose from drop-down list) Personal and domestic services

Trade Name (if different from Company Name) Two-digit PSIC code (automatic fill-out) 96

Company representative Contact number of Company representative

Designation of company representative Email address of Company representative

Signature of company representative

Business Address - Floor/Bldg/No/Street/Subdivision Tax Identification Number (TIN) of business/employer

Barangay/District SSS employer ID number

City/Municipality

Province and Region

Employee data
Total count of employees:
LIST OF AFFECTED WORKERS DUE TO COVID-19

Profile of Affected Workers

No. Name of Worker Employment Status

Designation Work arrangement during Tax Identification Social Security System

COVID* Number (TIN) (SSS) Number
Last name First name M.I (regular, contractual, etc.)

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(Please add below, as necessary)

* For the codes on possible work arrangements during COVID-19, please see below:
"RW" - Reduction of Workdays
"RE" - Rotation of Employees
"FL" - Forced Leave
"OTH" - Others (please specify)