Sss r5
Sss r5
Sss r5
TELEPHONE NUIVBER (AREA-coDE+rEL No ) MOBILE/CELLPHONE NUMBER E-MAIL ADDRESS WEBSITE (FoR BUSTNESS EMpLoyER)
PAYMENT DETAILS
APPLICABLE PERIOD SS CONTRIBUTION EC CONTRIBUTION TOTAL
(TO BE FILLED OUT BY EMPLOYER & INDIVIDUAL (TO BE FILLED OUT BY (TO BE FILLED OUT BY
MONTH YEAR PAYOR) EMPLOYER ONLY) EI\,4PLOYER ONLY)
January P P F
February
l\,4 a rch
April
May
June
July
August
September
October
November
Decem ber
A Penalty P F
D
F
D Underpayment
SUB-TOTAL F P F
TOTAL AMOUNT OF PAYMENT P
F9RM oF PAYMENT AMOUNT PAID IN FIGURES TOTAL AMOUNT PAID IN WORDS
n casir p
I Postat lVoney Order
E crrect<
Check Number PAID BY
Check Date
Bank & Branch Name
TOTAL AMOUNT PAID F PRINTED NAME SIGNATURE
DECLARATION OF EARNINGS OF INDIVIDUAL PAYOR
I hereby declare, for purposes of Sec. 19-A of the Social Security Law the amount of
(F=*--) as my monthly earnings, which shall be lhe basis of my monthly salary credit to be effective until revised in my next declaration.
I afflrm under the penalties of perjury. that this declaration has been made in good faith, and to the best of my knowiedge and belief, is true and
correct.