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Republic of the Philippines

SOCIAL SECURITY SYSTEM


R-5
EMPLOYER CONTRIBUTIONS
PAYMENT FORM
Please read instructions at the back before accomplishing this form
Print all information in capital letters and use black ink only (THIS IS YOUR OFFICIAL RECEIPT WHEN VALIDATED)
EMPLOYER NUMBER NAME OF EMPLOYER/REGISTERED BUSINESS

0 3 9 0 1 3 4 5 6 3 TRIPLE EXCELLENCE MARKETING SERVICES INC.


ADDRESS POSTAL CODE

TEMSI Bldg. 2264 Rubi St. San Andres Bukid, Manila


TYPE OF PAYOR TIN TELEPHONE/MOBILE NUMBER
Regular Employer Household Employer 0 0 0 - 1 7 7 - 7 6 1 ( 02) 563- 1919
APPLICABLE PERIOD EMPLOYEES'
SOCIAL SECURITY
COMPENSATION
TOTAL
MONTH YEAR CONTRIBUTION
CONTRIBUTION
JANUARY P P P
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
Sub-total P P P
PENALTY
UNDER

PENALTY
ADD

INTEREST

TOTAL REMITTANCE P P P
FORM OF PAYMENT AMOUNT IN FIGURES TOTAL AMOUNT IN WORDS
CASH P
Postal Money Order (PMO)
Check
Check Number CERTIFIED CORRECT
Date
Bank/Branch Name
TOTAL
12/08/2016
P SIGNATURE OVER PRINTED NAME DATE

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