Form Ui2.7 - Remuneration Received By The Employee Whilst Still In Employment 402s1i

UI-2.7 UNEMPLOYMENT INSURANCE FUND REMUNERATION RECEIVED BY THE EMPLOYEE WHILST STILL IN EMPLOYMENT To: The Claims Officer Statement in respect of payment made to the undermentioned Contributor who is still in my employment but is unable to work due to Illness, Maternity leave or the Adoption of a child. Full names of contributor: TANJA VAN ROOYEN 2

Employers UIF Reference No. ID No of contributor

7

8

2 0

1 9

9 1

3 7

9 0

/

8 6

3

2 0

0

8

8

(A) In of section 19(1), 24(2) and 27(3) of the abovementioned Act, I hereby certify that since (full date)

17 / 11 / 2014

, the contributor is on

Sick leave

 Maternity leave

Leave due to the adoption of a child and

has

 will

receive(d) the following remuneration

Gross remuneration (prior to confinement) Per Month / Per Week

Periods during which different rates of remuneration were received From

Gross remuneration received whilst on leave (PM/PW) NIL

To

30/11/2014 31/12/2014

To

31/01/2015

NIL

To

From

17/11/2014 01/12/2014

From

01/01/2015

From

To

From

To

From

To

NIL

(B)

The contributor is expected to return to work on ___01____/__02___/__2015____.

(C)

The contributor returned to work on __________/__________/___________.

DATE: ____________________ _________________________________________________ SIGNATURE OF EMPLOYER OR AUTHORISED AGENT BUSINESS STAMP