Weekly pay-periods worksheet
Optional Weekly Pay Periods Worksheet (or attach an insurable earnings report available through your Payroll Service Provider or Payroll Software Vendor to the ROE form
| Addendum to: (indicate ROE Serial No.) | Social Insurance Number: | ||||||
|---|---|---|---|---|---|---|---|
| Block 15C - Continued | |||||||
| p.p. | Insurable earnings | p.p. | Insurable earnings | p.p | Insurable earnings | ||
| 28 | 29 | 30 | |||||
| 31 | 32 | 33 | |||||
| 34 | 35 | 36 | |||||
| 37 | 38 | 39 | |||||
| 40 | 41 | 42 | |||||
| 43 | 44 | 45 | |||||
| 46 | 47 | 48 | |||||
| 49 | 50 | 51 | |||||
| 52 | 53 | ||||||
| I am aware that it is an offense to make false entries and hereby certify that all statements on this addendum form are true. | |||||||
| Signature of issuer | Name of issuer (please print) | Date | |||||
| D | M | Y | |||||
Note to the employee
This addendum should remain attached to the record of employment with the serial number indicated above.
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