Form C.63 - Claim For Refund Of Contributions
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1
2The National Insurance Act, 1972
Commonwealth of The Bahamas
C
R
C
LAIM FOR
EFUND OF
ONTRIBUTIONS
For official use only
Section A: To be completed by Employer/Self-Employed Person:
1. Name of Business/Self-Employed Person: _______________________________
2. N.I. #:
3. Telephone #: _______________________________________________________
4. P. O. Box: ___________________ 5. Street Address: _____________________________________________
6. How did the contributions come to be paid in error?
(Please tick one)
Maternity Benefit
Sickness Benefit
Industrial Benefit
Duplicate Payment
Other
please specify): _____________________________________________________________________
(
7. Were contributions deducted from employee’s wages?
Yes
No
8. I declare that the contributions as described in Section C (or on the separate sheet) were paid in error. As the
Employer/Self-Employed person, I claim refund of the amount paid less any amount owed to National Insurance.
9. Print Name: ____________________________
10. Position: ______________________________________
11. Signature: _______________________________________
Date: ___________________________________
dd/mm/yyyy
Affix Employer/Self Employed Stamp
or Seal in box
Section B: Particulars of Employed Person
12.
Mr./
Mrs./
Ms. ________________________________________________________________________
Last Name
First Name
Middle Name(s)
13. N.I.#:
14. Date of Birth: ____________________________________
dd/mm/yyyy
15. House # & Street: _________________________________________
16. Home Phone: _________________
17. Work Phone: _______________________________
18. Cell Phone: ________________________________
19. P.O. Box: _____________________
20. Email Address: ___________________________________________
21. In the event of more than one employer, provide name of:-
Primary Employer: ___________________________________________________________________________
Secondary Employer: ________________________________________________________________________
Form C.63 (Revised 2011)
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