THE NATIONAL INSURANCE BOARD NI 187

SUMMARY OF NATIONAL INSURANCE CONTRIBUTIONS DUE/IN ARREARS

Instructions:
1. Please complete this form in duplicate.
WARNING: SUBMISSION OF FALSE OR MISLEADING INFORMATION IS AN OFFENSE PUNISHABLE BY LAW

SECTION "A" - EMPLOYER INFORMATION FOR OFFICIAL USE

TOP GRADE CONSTRUCTION LTD S.C. CODE
EMPLOYER'S TRADE NAME:
8 0 4 4 0 0
ADDRESS:
LP 57 DILLON STREET DIEGO MARTIN

EMPLOYER REG NO:

3 5 6 - 9 3 7 9 1 4 2 7 0 8
TELEPHONE NO:

CONTRIBUTIONS DUE FOR PAY PERIOD: 2 0 1 5 0 1 1 9 TO 2 0 1 5 0 1 3 1

YYYY MM DD YYYY MM DD

WHERE THE PERIOD EXCEEDS ONE MONTH, COMPLETE SECTION F NO. OF EMPLOYEES BEING PAID FOR: 4
GIVING SEPARATE DETAILS FOR EACH MONT:

SECTION "B" - VALUE OF CONTRIBUTIONS PAYABLE SECTION "C" - METHOD OF PAYMENT

$ c (1) (2)
(a) BALANCE B/F
HOW PAID AMOUNT
$ c
(b) CONTRIBUTIONS DUE 715 20 CASH
(State details overleaf) 2788 89
(c) PENALTY (If Applicable) 715 20
CHEQUE
(d) INTEREST (If Applicable)
1358 49 (State details overleaf)
(e) TOTAL AMOUNT DUE (a+b+c+d)
2788 89 TOTAL
(f) AMOUNT PAID

(g) BALANCE C/F

SECTION "D" - CERTIFICATE OF DECLARANT

I solemnly and sincerely declare that the information given is a correct reflection of my employee population and National Insurance
obligations.
COMPANY STAMP
HAPTY PRINCE
NAME:

SIGNATURE:

MANAGING DIRECTOR 2 0 2 1 0 71 3
POSITION: DATE:
YYYY MM DD

SECTION "E" - FOR OFFICIAL USE

NI 184 RECEIVED DISKETTE RECEIVED

AMOUNT RECEIVED $ RECEIPT NO.

SIGNATURE OF CSR
 2/NI 187

SECTION "F" - DETAILS OF PAYMENTS FOR PERIODS EXCEEDING ONE MONTH

FROM TO

YR/MTH/DAY YR/MTH/DAY CONTRIBUTIONS PENALTY INTEREST TOTAL NO. OF FOR OFFICIAL USE
DUE EMPLOYEES
$ C $ C $ C $ C $ C TRANSACTION SLIP #

* TOTAL

* Enter amounts on page 1. Sec B

CASH DETAILS CHEQUE DETAILS

AMOUNT BANK AND CHEQUE NUMBER AMOUNT
DENOMINATION $ C $ C
$ 100 X
$ 20 X
$ 10 X
$ 5 X
$ 1 X
COINS

TOTAL