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(CITY/PROVINCE) APPLICABLE PERIOD MONTH YEAR INSTRUCTIONS 1. CHECK THE BOX TO INDICATE THE TYPE OF PAYOR REGULAR EMPLOYER INDICATE THE YEAR FOR WHICH PAYMENT IS APPLICABLE. REMIT YOUR EMPLOYEE S/HOUSEHOLD HELPER S MONTHLY CONTRIBUTIONS ON OR BEFORE THE 5TH DAY OF THE FOLLOWING MONTH TO AVOID THE 3% PENALTY PER MONTH FOR LATE PAYMENT. 7. 8. TOTAL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER ADD UNDER OVER PAYMENT ATTACH YOUR EXTRA COPY OF THIS FORM AND SPECIAL BANK RECEIPT WHEN.

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