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SSS
EC
3A POSTAL CODE
DATE OF COVERAGE
S
H
(MAIL CODE)
CITY CODE
10 COMPANY SICK LEAVES PAID DURING CONFINEMENT (CURRENT SICK LEAVE WITH FULL PAY ONLY)
(a) Started on (MO - DA- YR)
11
12
COMPUTATION
(a)
TOTAL MSC
(b)
DIVIDED BY 180 =
(c)
(d)
MULTIPLIED BY 90%
(e)
(f)
(g)
COMPENSATION DUE
Year
Applicable Month
Salary Credit
SIGNATURE OF EMPLOYEE
DATE ACCOMPLISHED
OFFICIAL DESIGNATION
TO BE FILLED BY EMPLOYER-CLAIMANT
EMPLOYER
ACKNOWLEDGMENT RECEIPT
EMPLOYEE
ADDRESS
OTHER DOCUMENTS SUBMITTED
SS NO.
Date:
DO NOT FILL
Others
To
Date Filed
Received By