Social Security Board - Monthly Remittance Form
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1SOCIAL SECURITY BOARD
MONTHLY REMITTANCE FORM
MONTH
YEAR
EMPLOYER_________________________________________
EMPLOYER
NUMBER
Employee’s
No. of
S
EARNINGS AND CONTRIBUTION
Total
Total
Weeks
Registration
Earnings
8 ½
Name of Employees
E
COMMENTS
Worked
Number
Week No. 1
Week No. 2
Week No. 3
Week No. 4
Week No. 5 or
Contribution
For Month
X
Monthly Salary
Earnings
Employee 4%
Employer 4.5%
Earnings
Employee 4%
Employer 4.5%
Earnings
Employee 4%
Employer 4.5%
Earnings
Employee 4%
Employer 4.5%
Earnings
Employee 4%
Employer 4.5%
Earnings
Employee 4%
Employer 4.5%
I certify that the above contributions are due in respect of the employees listed, for the periods shown and I enclose cheque/cash in payment.
TOTALS
Surcharge (5% Total Contributions)
GRAND TOTALS
Signature of Employer___________________________________
Date____________________________
OFFICIAL USE ONLY
CHEQUE NUMBER
Cashier ____________________ Receipt No._________________ Date_________________ Verified _____________
Posted ____________________ Date______________________ Checked____________________________________
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