Republic of the Philippines SBR NO.

POST MARK/SBR DATE TELLER’S INITIAL

SOCIAL SECURITY SYSTEM

R-5 CONTRIBUTIONS AMOUNT
REV. 02-98 PAYMENT RETURN
DATE
(TO BE SUBMITTED IN QUADRUPLICATE)
(THIS IS YOUR OFFICIAL RECEIPT WHEN VALIDATED)
EMPLOYER’S ID NUMBER EMPLOYER’S REGISTERED NAME

ADDRESS POSTAL CODE

(NO. & STREET) (BARANGAY)

(CITY/PROVINCE) TEL. NO.

(TOWN/DISTRICT)

APPLICABLE PERIOD SOCIAL SECURITY EMPLOYEE COMPENSATION

CONTRIBUTION TOTAL
INSTRUCTIONS MONTH YEAR CONTRIBUTION

JANUARY
1. CHECK THE BOX TO INDICATE THE TYPE OF
PAYOR FEBRUARY
REGULAR EMPLOYER MARCH
HOUSEHOLD EMPLOYER APRIL
2. INDICATE THE YEAR FOR WHICH PAYMENT MAY
IS APPLICABLE.
JUNE
3. REMIT YOUR EMPLOYEE’S/HOUSEHOLD
HELPER’S MONTHLY CONTRIBUTIONS ON
JULY
OR BEFORE THE 5TH DAY OF THE
AUGUST
FOLLOWING MONTH TO AVOID THE 3%
PENALTY PER MONTH FOR LATE PAYMENT. SEPTEMBER
4. REMIT YOUR PAYMENT EITHER: OCTOBER
a) THROUGH SSS ACCREDITED BANK; OR NOVEMBER
b) BY REGISTERED MAIL
DECEMBER
5. MAKE ALL CHECKS AND POSTAL
MONEY ORDERS PAYABLE
PENALTY PAYMENT

TO SSS
UNDER
ADD

PENALTY REFERENCE NUMBER

6. ATTACH YOUR EXTRA COPY

PAYMENT

OF THIS FORM AND SPECIAL

LESS
OVER

BANK RECEIPT WHEN

SUBMITTING THE
CORRESPONDING
CONTRIBUTION FORM R-3
(CONTRIBUTION COLLECTION
LIST) OR R-3 TAPE/ DISKETTE. TOTAL REMITTANCE P P P
7. SUBMIT YOUR FORM R-3 WITHIN FIVE (5)
FORM OF PAYMENT AMOUNT TOTAL AMOUNT IN WORDS:
DAYS AFTER THE APPLICABLE QUARTER CASH P______________________
OR YOUR R-3 TAPE/DISKETTE ON OR
BEFORE THE 10TH DAY OF THE MONTH CHECK P______________________
FOLLOWING THE APPLICABLE MONTH
TO THE NEAREST SSS OFFICE OR BANK NAME : _____________________________ CERTIFIED CORRECT:
THROUGH POSTAL SERVICES OFFICE.
CHECK NO. : ______________________________
8. INDICATE YOUR PENALTY REFERENCE
NUMBER, IF ANY, FOR PAYMENT OF DATE : ______________________________
PENALTIES.
TOTAL P______________________ SIGNATURE OVER PRINTED NAME