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Please carefully read instructions on reverse before completing this form COMMONWEALTH OF THE BAHAMAS THE NATIONAL INSURANCE ACT 1972 SELF-EMPLOYED or VOLUNTARILY INSURED FORM C. 10 SE or V MONTHLY CONTRIBUTION STATEMENT NAME REGISTRATION TELEPHONE NI ADDRESS CELLULAR ISLAND EMAIL ADDRESS FAX Please complete ALL fields in this box. Please carefully read instructions on reverse before completing this form COMMONWEALTH OF THE BAHAMAS THE NATIONAL INSURANCE ACT 1972 SELF-EMPLOYED or VOLUNTARILY INSURED FORM C. 10 SE or V MONTHLY CONTRIBUTION STATEMENT NAME REGISTRATION TELEPHONE NI ADDRESS CELLULAR ISLAND EMAIL ADDRESS FAX Please complete ALL fields in this box. RETURN OF CONTRIBUTIONS DUE C10 YEAR C10 MONTH OF MONDAYS IN THE MONTH CONTRIBUTION TYPE WEEKLY/ MONTHLY 0F WEEKS INSURABLE INCOME RETIREMENT INDICATOR TOTAL CONTRIBUTIONS DUE NO CENTS TOTAL CERTIFICATION I hereby certify that the information given above is true and correct FOR OFFICIAL USE ONLY Contributions Paid Signature Amount Interest Installment Agreement Name Other Date TOTAL PAYMENT Must be supported by NIB receipt WEEKLY/MONTHLY - W eekly Paid M onthly Paid / CONTRIBUTION TYPE - A Self-Employed V oluntarily Insured / RETIREMENT INDICATOR Not Retired R etired V oluntarily Insured C. 10 SE or V MONTHLY CONTRIBUTION STATEMENT NAME REGISTRATION TELEPHONE NI ADDRESS CELLULAR ISLAND EMAIL ADDRESS FAX Please complete ALL fields in this box. RETURN OF CONTRIBUTIONS DUE C10 YEAR C10 MONTH OF MONDAYS IN THE MONTH CONTRIBUTION TYPE WEEKLY/ MONTHLY 0F WEEKS INSURABLE INCOME RETIREMENT INDICATOR TOTAL CONTRIBUTIONS DUE NO CENTS TOTAL CERTIFICATION I hereby certify that the information given above is true and correct FOR OFFICIAL USE ONLY Contributions Paid Signature Amount Interest Installment Agreement Name Other Date TOTAL PAYMENT Must be supported by NIB receipt WEEKLY/MONTHLY - W eekly Paid M onthly Paid / CONTRIBUTION TYPE - A Self-Employed V oluntarily Insured / RETIREMENT INDICATOR Not Retired R etired V oluntarily Insured C..

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