Business Name:_______________________________ Assessment Month:_____________________ Employer Name:_______________________________ Registration No.: Nature of Business:_____________________________ No. of Employees: _____________________ DOMINICA SOCIAL SECURITY COLLECTION OF CONTRIBUTIONS CONTRIBUTIONS REMITTANCE FORM C8 Address:______________________________________ Phone No.:____________________________________ Details of Employment Employee Name Number Gross Earnings ($) Date of Pay Cont (Comm) Job Description Rate Freq /Term Week 1 Date Week 2 Date Week 3 Date Week 4 Date Contributions Total Wages Week 5 Date Weekly For Official Use Only Details Cheque No. Amount Due Amount Paid 0.00 Comments Current Liability: 0.00 0.00 0.00 Date: _________________________ Note: This form with the remittance of the total contributions payable in respect of wages paid in any month must reach Checked by: __________ Date:________________ _____________________ Late Fee (10% if applicable):____________ Signature: _________________________ Late Fees Totals payable by me/us as per wages book and employee records plus surcharge, if applicable. 0.00 Contributions Total Due I/We submit the sum of $__________________ and certify that this is the total amount Receipt No. Dr./Cr. Bal. Employee Employer Due Due 0.00 Total Wages Date of Payment _____________________ the Social Security Office before the 14th of the following month. If it is submitted after the 14th, add 10% late fees. Total Liability:____________