DOLE SAP-CBF Form No.

04-15

CASH BONUS SPECIAL PAYROLL

CROP YEAR____________

_____________________________________ LOPEZ SUGAR CORPORATION

Name of Planter Sugar Mill Where Cane was Milled

_____________________________________ _____________________________________
Name of Plantation/Mill Net Share in Production (LKG)

_____________________________________ ______________________________________
Location of Farm Total CBF for Distribution

UNITED SAGAY-ESCALANTE-TOBOSO PLANTERS ASSN., INC.

Planter’s Association Affiliated
No. NAMES TOTAL PERIOD CASH
OF SALARY OF BUNOS SIGNATURE DATE
WORKERS/EMPLOYEES CREDIT EMPLOYMENT DUE RECEIVED
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
TOTAL
Certified Correct:

_______________________________ _______________________________
Planter/Mill Officer Planter/General Manager
_______________________________ _______________________________
Date Date
___________________________________________________________________________________________________
(Please do not full up this portion. To be accomplished by DOLE SAP officer only)

Summary of Findings:

Result of payroll audit (Please tice appropriate box)

1. Completeness of required date/information 2. Accuracy of computation

( ) Yes ( ) No ( ) Yes ( )N
3.Status of Distribution
( ) Total CBF Distribution (100%) ( ) Total CBF Distributed P ____________
( ) Undistribute Amount P ____________

Verified: ________________________________
Name and Signature of SAP Officer
Department of Labor and Employment
Date: ___________________________

/121C 02-19-16