SOCIAL SECURITY SYSTEM CONTRIBUTIONS PAYMENT FORM

1 Self-EmployedNon-Working SpouseVoluntaryFarmer/FishermanOFW (Foreign Address - City, Country _____ )EMPLOYER NUMBERSS NUMBER (10 DIGITS)COMMON REFERENCE NUMBER (IF ANY, 12 DIGITS)EMPLOYER NAMENAMEADDRESS( NO. & BLDG. NAME)(HOUSE/LOT & BLK. NO.)(STREET NAME)(SUBDIVISION)(BARANGAY/DISTRICT/LOC ALITY)(CITY/MUNICIPALITY)(PROVINCE)ZIP CODETAX IDENTIFICATION NUMBER (IF ANY)TELEPHONE NUMBER (AREA CODE+TEL. NO.)MOBILE/CELLPHONE NUMBERE-MAIL ADDRESSWEBSITE (FOR BUSINESS EMPLOYER)TOTAL(TO BE FILLED OUT BY EMPLOYER ONLY)Republic of the PhilippinesSOCIAL SECURITY SYSTEMCONTRIBUTIONS(THIS IS YOUR OFFICIAL RECEIPT WHEN VALIDATED)TO BE FILLED OUT BY EMPLOYER AND INDIVIDUAL PAYORPAYOR's COPYPLEASE READ THE INSTRUCTIONS ATTHE BACK BEFORE FILLING OUTTHIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS ANDUSE BLACK INK PERIODTO BE FILLED OUT BY INDIVIDUAL PAYORTO BE FILLED OUT BY EMPLOYERPAYMENT DETAILSMONTHPAYMENT FORMB usinessHouseholdSS CONTRIBUTION(TO BE FILLED OUT BY EMPLOYER & INDIVIDUAL PAYOR)EC CONTRIBUTION(TO BE FILLED OUT BYEMPLOYER ONLY)YEARCON-01181 (05-2014)PPPPPPPPPTOTAL AMOUNT OF PAYMENTPFORM OF PAYMENTTOTAL AMOUNT PAID IN WORDSCashPPostal Money OrderCheck Check NumberPAID BY Check Date Bank & Branch NameTOTAL AMOUNT PAIDPOO)SIGNATUREI hereby declare, for purposes of Sec.

2 19-A of the SOCIAL SECURITY Law the amount of _____(P _____) as my monthly earnings, which shall be the basis of my monthly salary credit to be effective until revised in my next declaration. I affirm under the penalties of perjury, that this declaration has been made in good faith, and to the best of my knowledge and belief, is true and Underpayment AMOUNT PAID IN FIGURESJunePRINTED NAMEJulyO)OO)ADD PenaltyDECLARATION OF EARNINGS OF INDIVIDUAL PAYORD ecemberSUB-TOTALA ugustMaySeptemberOctoberNovemberAprilPRI NTED NAME OF MEMBERSIGNATURE OF indicate "N/A" or "Not Applicable", if the required data is not Pay through any of the following:a. SSS Branch with Tellering Facilitiesb. Accredited Banksc. Post Officed. Bayad Centerse. SM Business For business employer-b. For household Individual Payor (Self-Employed, Voluntary Member, Non-Working Spouse, Farmer/Fisherman and Overseas Filipino Worker) number- Full name as registered with the SSS- Common Reference Number (CRN), if any-9-digit personal TIN if any9 or 0 Last day of the monthIn case the PAYMENT deadline falls on a Saturday, Sunday or holiday, PAYMENT may be made on the next working day.

3 Accomplish appropriate boxes as follows:Accomplish appropriate boxes as follows:Make all checks and postal money orders payable to SSS. Fill out properly the check details in the "Form of PAYMENT " or 825th day of the monthemployer number, household employer name, home address and 9-digit personal TIN, if any as registered with the SSSAs business/household employer, pay your CONTRIBUTIONS following the PAYMENT deadline to avoid the three percent (3%) penaltyper month for late the 10th digit of the 13-digit Employer (ER) is: PAYMENT Deadline(following the applicable month)INSTRUCTIONSS ubmit immediately a copy of validated " CONTRIBUTIONS PAYMENT Form" or " CONTRIBUTIONS PAYMENT Form" with Special Bank Receipt(SBR) together with the corresponding " CONTRIBUTIONS Collection List" or " CONTRIBUTIONS Collection List" in electronic media deviceto the nearest SSS number, business name, business address and 12-digit business TIN as registered with the SSS1 or 210th day of the month3 or 415th day of the month5 or 620th day of the month-9-digit personal TIN, if any2.

4 Pay your CONTRIBUTIONS following the PAYMENT deadline to avoid application of payments For Self-Employed, Voluntary, Non-Working Spouse, Farmer/Fishermanb. For Overseas Filipino Worker (OFW) out the following , the following shall be observed: You may also visit the SSS Website at other PAYMENT Keep all your validated PAYMENT forms for future the present MSC is more than P10, and the age of the member is 55 years old or older, the allowed increaseis only one (1) salary bracket regardless of whether the supporting documents are submitted or for October to December of a given year may also be paid until 31 January of the succeeding case the PAYMENT deadline falls on a Saturday, Sunday or holiday, PAYMENT may be made on the next working day. Otherwise,late contribution payments shall be applied prospectively."SS" column only of the " PAYMENT DETAILS" portion (need not fill out the "Total" column).

5 CONTRIBUTIONS for January to December of a given year may be paid anytime within the same or 620thday of the month7 or 825thday of the month"Declaration of Earnings of Individual Payor" portion if you want to change your monthly salary credit (MSC) to more thantwo (2) salary brackets higher or lower than your present or 210thday of the month3 or 415thday of the month9 or 0 Last day of the monthPayment Deadline(following the applicable month or quarter)SS number ends in:If the 10th digit of the REMINDERSThe total CONTRIBUTIONS paid by the Employer in this PAYMENT form includes the SOCIAL SECURITY CONTRIBUTIONS shared by both theemployer and employee plus the EC CONTRIBUTIONS shouldered solely by the employer, in accordance with the SSS monthlycontribution OFW, the minimum MSC shall be P5, Hence, any change lower than the minimum MSC shall not be SpouseVoluntaryFarmer/FishermanOFW (Foreign Address - City, Country _____ )EMPLOYER NUMBERSS NUMBER (10 DIGITS)COMMON REFERENCE NUMBER (IF ANY, 12 DIGITS)EMPLOYER NAMENAMEADDRESS( NO.)

6 & BLDG. NAME)(HOUSE/LOT & BLK. NO.)(STREET NAME)(SUBDIVISION)(BARANGAY/DISTRICT/LOC ALITY)(CITY/MUNICIPALITY)(PROVINCE)ZIP CODETAX IDENTIFICATION NUMBER (IF ANY)TELEPHONE NUMBER (AREA CODE+TEL. NO.)MOBILE/CELLPHONE NUMBERE-MAIL ADDRESSWEBSITE (FOR BUSINESS EMPLOYER) PAYMENT FORMB usinessHouseholdSS CONTRIBUTION(TO BE FILLED OUT BY EMPLOYER & INDIVIDUAL PAYOR)EC CONTRIBUTION(TO BE FILLED OUT BYEMPLOYER ONLY)YEARMONTHSOCIAL SECURITY SYSTEMCONTRIBUTIONS(THIS IS YOUR OFFICIAL RECEIPT WHEN VALIDATED)TO BE FILLED OUT BY EMPLOYER AND INDIVIDUAL PAYORPAYMENT DETAILSSSS' COPYPLEASE READ THE INSTRUCTIONS ATTHE BACK BEFORE FILLING OUTTHIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS ANDUSE BLACK INK PERIODTO BE FILLED OUT BY INDIVIDUAL PAYORTO BE FILLED OUT BY EMPLOYERTOTAL(TO BE FILLED OUT BY EMPLOYER ONLY)Republic of the PhilippinesCON-01181 (05-2014)PPPPPPPPPTOTAL AMOUNT OF PAYMENTPFORM OF PAYMENTTOTAL AMOUNT PAID IN WORDSCashPPostal Money OrderCheck Check NumberPAID BY Check Date Bank & Branch NameTOTAL AMOUNT PAIDPN ovemberAprilO)OO)DECLARATION OF EARNINGS OF INDIVIDUAL PAYORD ecemberSUB-TOTALA ugustMarch Underpayment AMOUNT PAID IN FIGURESJunePRINTED NAMEJulyMaySeptemberOctoberI hereby declare, for purposes of Sec.

7 19-A of the SOCIAL SECURITY Law the amount of _____(P _____) as my monthly earnings, which shall be the basis of my monthly salary credit to be effective until revised in my next declaration. I affirm under the penalties of perjury, that this declaration has been made in good faith, and to the best of my knowledge and belief, is true and PenaltyOO)PRINTED NAME OF MEMBERSIGNATURE OF indicate "N/A" or "Not Applicable", if the required data is not Pay through any of the following:a. SSS Branch with Tellering Facilitiesb. Accredited Banksc. Post Officed. Bayad Centerse. SM Business For business employer-b. For household Individual Payor (Self-Employed, Voluntary Member, Non-Working Spouse, Farmer/Fisherman and Overseas Filipino Worker) number- Full name as registered with the SSS- Common Reference Number (CRN), if any-9-digit personal TIN if any9 or 0 Last day of the monthIn case the PAYMENT deadline falls on a Saturday, Sunday or holiday, PAYMENT may be made on the next working day.

8 Accomplish appropriate boxes as follows:Accomplish appropriate boxes as follows:Make all checks and postal money orders payable to SSS. Fill out properly the check details in the "Form of PAYMENT " or 825th day of the monthemployer number, household employer name, home address and 9-digit personal TIN, if any as registered with the SSSAs business/household employer, pay your CONTRIBUTIONS following the PAYMENT deadline to avoid the three percent (3%) penaltyper month for late the 10th digit of the 13-digit Employer (ER) is: PAYMENT Deadline(following the applicable month)INSTRUCTIONSS ubmit immediately a copy of validated " CONTRIBUTIONS PAYMENT Form" or " CONTRIBUTIONS PAYMENT Form" with Special Bank Receipt(SBR) together with the corresponding " CONTRIBUTIONS Collection List" or " CONTRIBUTIONS Collection List" in electronic media deviceto the nearest SSS number, business name, business address and 12-digit business TIN as registered with the SSS1 or 210th day of the month3 or 415th day of the month5 or 620th day of the month-9-digit personal TIN, if any2.

9 Pay your CONTRIBUTIONS following the PAYMENT deadline to avoid application of payments For Self-Employed, Voluntary, Non-Working Spouse, Farmer/Fishermanb. For Overseas Filipino Worker (OFW) out the following , the following shall be observed: You may also visit the SSS Website at other PAYMENT Keep all your validated PAYMENT forms for future the present MSC is more than P10, and the age of the member is 55 years old or older, the allowed increaseis only one (1) salary bracket regardless of whether the supporting documents are submitted or for October to December of a given year may also be paid until 31 January of the succeeding case the PAYMENT deadline falls on a Saturday, Sunday or holiday, PAYMENT may be made on the next working day. Otherwise,late contribution payments shall be applied prospectively."SS" column only of the " PAYMENT DETAILS" portion (need not fill out the "Total" column).

10 CONTRIBUTIONS for January to December of a given year may be paid anytime within the same or 620thday of the month7 or 825thday of the month"Declaration of Earnings of Individual Payor" portion if you want to change your monthly salary credit (MSC) to more thantwo (2) salary brackets higher or lower than your present or 210thday of the month3 or 415thday of the month9 or 0 Last day of the monthPayment Deadline(following the applicable month or quarter)SS number ends in:If the 10th digit of the REMINDERSThe total CONTRIBUTIONS paid by the Employer in this PAYMENT form includes the SOCIAL SECURITY CONTRIBUTIONS shared by both theemployer and employee plus the EC CONTRIBUTIONS shouldered solely by the employer, in accordance with the SSS monthlycontribution OFW, the minimum MSC shall be P5, Hence, any change lower than the minimum MSC shall not be SpouseVoluntaryFarmer/FishermanOFW (Foreign Address - City, Country _____ )EMPLOYER NUMBERSS NUMBER (10 DIGITS)COMMON REFERENCE NUMBER (IF ANY, 12 DIGITS)EMPLOYER NAMENAMEADDRESS( NO.)