R-5 - Contributions Payment Return

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SBR NO.
POST MARK/SBR
DATE
TELLER’S INITIAL
Republic of the Philippines
R-5
CONTRIBUTIONS
AMOUNT
PAYMENT RETURN
REV. 02-98
DATE
(TO BE SUBMITTED IN QUADRUPLICATE)
(THIS IS YOUR OFFICIAL RECEIPT WHEN VALIDATED)
EMPLOYER’S ID NUMBER
EMPLOYER’S REGISTERED NAME
POSTAL CODE
ADDRESS
(NO. & STREET)
(BARANGAY)
TEL. NO.
(CITY/PROVINCE)
(TOWN/DISTRICT)
APPLICABLE PERIOD
SOCIAL SECURITY
EMPLOYEE COMPENSATION
T O T A L
CONTRIBUTION
MONTH
YEAR
INSTRUCTIONS
CONTRIBUTION
JANUARY
1.
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
TOTAL REMITTANCE
P
P
P
FORM OF PAYMENT
AMOUNT
TOTAL AMOUNT IN WORDS:
P
CASH
______________________
CHECK
P
______________________
BANK NAME : _____________________________
CERTIFIED CORRECT:
CHECK NO. : ______________________________
DATE
: ______________________________
SIGNATURE OVER PRINTED NAME
P
TOTAL
______________________

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