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

This addendum should remain attached to the record of employment with the serial number indicated above.

(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

This addendum should remain attached to the record of employment with the serial number indicated above.