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

Note to the employee

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

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