FORM 14 ‘WORKERS’ COMPENSATION FUND CONTROL BOARD Office of the Senior Branch Manager ‘Compensation House, Cairo Road P.O Box 31185, ‘el: 02-11 228765 LUSAKA HEAD OFFICE ADDRESS. Workers’ Compensation Commissioner P.O Box 71534 Tel: 02-12 6 10482/8 NDOLA, STATEMENT AND ESTIMATE OF EARNINGS OF WORKERS (Section 112 subsection (1) ‘This form must be completed and returned to the Workers’ Compensation Commissioner, P.O. Box 71524, Neola, or Rearest Branch office not later than 18TH April 2018, or within fourteen days ofthe commencement of business, whichever date is the later. 925 menoreeatece yt A2ASs semi iat fe ens BRA TPH Ee LEE ‘SEPARATE FORMS MUST BE USED FOR EACH CLASS OF BUSINESS CARRIED ON BY AN EMPLOYER we SE oe Seat AN SERRIESS SSTS, 1. STATEMENT OF EARNINGS: Siateto the nearest Kwacha the (otal earnings paid during the period 11 April 2017 to 31 March, 2018 in respect ofall workers, Where the earnings of any worker exceeds ZMW 9,600.00, chen only ZAW 9,600.00 (Nine Thousand Six Hundred Kwacha) should be declared in respect of that worker (FOR THE MEANING OF “EARNINGS” see notes {i -(v] below) ‘A Wamber of workers employed 5 ] “Total earnings of all workers Za 35,000.00 ‘C._Add 12.5% of total earning Za 6, 000.00 "TOTAL OF B and C above ‘zaW| 54, 000.00, 2. ESTIMATE OF EARNINGS: Give below an estimate tothe nearest Kwacha ofthe total earnings which you expect to pay during the financial year 1% April 2018 to 31% March, 2019 in respect of all workers. Where earnings of any worker exceeds ZAFW 8,600.00 per szinim, only ZMW 9,600.00 (Nine ‘Thousand Six Hundred Kwacha) is tobe declared in respect of that worker (FOR THE MEANING OF “BARNINGS” see notes fi) - lJ) below) ‘A, Number of workers Uiely to be employed during the year RE B, Total earnings of all workers: ZMw_| 48, 000.00 C. Add 12.5% of total earnings ‘ZMWw_| 6, 000.00. ‘TOTAL OF B and C above ‘zuw | 84, 000.00 3, State names and address ofall branches, ete covered by this return on separate sheet 44,_State the precise nature of your trade, work, business ar profession NOTE: jj For the purpose ofthis return a worker is any person, other than a person employed casually and not in connection with ‘the employer's trade of business, who has entered into works tinder a contract of service of apprenticeship or learnership with an employer, (i) all earnings paid or to be paid by sub-contractors not otherwise registered as employers with the Workers! ‘Compensation Commissioner must be ascertained and inched (i), Where a worker earns over ZMW 9,600.00 per annum only ZMW 9,600.00 (Nine Thousand Six Hundred Kwacha) should be Ueclared in sespectof that worker liv) Should any employer require further information as to completing of this return he should consult his local ‘Workers’ Compensation Office, Tere ceriy Ghat to the beat of my Knowledge all partculara in ia renur ae true, gina ea maa oa yo mon 2D RECTOR STAMP. PROVISIONAL ASSESSMENT. Less Prov ‘Total ‘Rate| Amount Due | Assessment | Balance | Total Earnings | Rate| Amount Due _| Total Amount Due IMPORTANT NOTE: A DUPLICATE COPY OF THIS FORM IS ATTACHED FOR YOUR RECORD.