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T AGENCY M1-1 MONTH YEAR (Please read instructions at the back) NAME OF EMPLOYER EMPLOYER SSS NO. FOR PRIVATE EMPLOYER ADDRESS OF EMPLOYER FOR GOV T EMPLOYER ZIP CODE TIN NAME OF EMPLOYEES AGENCY BRANCH REGION CODE CODE CODE TELEPHONE NO/S. CONTRIBUTIONS Pag-IBIG ID No./ DATE OF BIRTH (Family Name First Name Middle Name) TOTAL EMPLOYER EMPLOYEE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

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