UNEMPLOYMENT INSURANCE ACT 63 OF 2001 UI-19

Employers Declaration of Employees for the month of

Information to be supplied in terms of Section 56(1&3) read with Regulation 13(1&2)
An employer must by the seventh day of each month inform the Commissioner of any changes arising during the previous month regarding the employer's contact details or employees remuneration details
including new appointments and termination of service. The employer must forward this form to the Unemployment Insurance Fund at (012) 337-1943/44 or 337-1580/81/82 or submit same at any branch
of the UIF which is closest to the employer. The completed form can also be faxed to any of the following numbers: Pta (012) 309 5142/5286; Jhb (011) 497 3293; Dbn (031) 366 2156; Polokwane
(015) 290 1670; Mmabatho (018) 384 2658; East Ldn (043) 701 3263; Blftn (051) 447 9353; CT (021) 441 8024;Wtb (013) 656 0233;PE (041) 586 1541;Gmn (011) 873 2219;George (044) 873 2568;
Pmb (033) 394 5069; Kimberley (053) 832 7218. .
1. EMPLOYER DETAILS
1.1 UIF Employer Reference No 2 1 7 0 2 0 0 / 3 Branch No 1.2 PAYE Reference No (If registered with 7 1 2 0 7 8 2 6 5 3
SARS)
1.3 Trading name of business Quatro Security Services 1.4 Physical Address Libertas Office Park, Block E, Equestria, Pta
1.5 Address where employees listed in Item 2 work (if different to the address in 1.4) 1.6 Postal address Postnet Suite # 0532, Private Bag X1, Die Wilgers 0041
1.7 Co. Reg.No (CIPRO No) 2 0 1 2 / 1 0 7 5 6 3 / 0 7
1.8 E-mail address [email protected] 1.9 Fax No 1.10 Phone No 0861440000 1.11Authorised person** M.Ludick
2. EMPLOYEE DETAILS
A B C D* E* F G H I J ***
Surname Initial ID Number Total (Gross) Total Commencement date of Termination Date Reason for Indicate If non-
s (13 Digit bar-coded RSA ID No) Remuneration paid Hours Employment Termination whether Contrib
to Employee Per Worked (Use contributor utor
Month during Termination or non- state
Codes as
Month contributor reason
supplied at the
(YES OR (Use
bottom of the
NO) codes at
page)
bottom of
page)
R c D D M M Y Y D D M M Y Y

LEKGOOA NS 6096 00 208 0 1 0 3 1 8 0 2 0 4 2 4 13 Y

9 3 1 2 1 8 5 3 9 6 0 8 2

I, Khomotso, Rosa Teffo (Name of Employer), ID No: 8612021220086, declare that the above information is true and correct. I understand that it is an offence to make
a false statement.

EMPLOYER SIGNATURE: DATE: 26/05/2025

DESCRIPTIONS Code (J) Reason for Non-Contribution *** Employer Stamp
** If the employer is not resident in the RSA, or is a body corporate not registered in the RSA, an authorised person must carry 1 Temporary employees (less that 24 hours per month) (if available)
out the duties of the employer in terms of this Act. 2 Employees who earn commission only
D* Remuneration means actual basic salary plus payment in kind (Declare actual gross salary) 3 No income paid for the payroll period
If paid Weekly, convert wages to monthly salary (weekly wages X 52/12)
E* Total Hours Worked ie. Actual hours worked during the month (only applicable for employees that are paid per hour)
Employers may also submit these details electronically from payrolls or on the UIF’s website at www.labour.gov.za
* Only Applicable for Commercial employers, Domestic employers – provide Surname and initials
** Constructive dismissal can only be determined by the CCMA: Bargaining-Council or Labour Court
**

REASON FOR TERMINATION CODES

2 Deceased 6 Resigned 10 Illness /Medically boarded 14 Business Closed 18 Commissioning Parental
3 Retired 7 Constructive Dismissal**** 11 Retrenched/Staff Reduction 15 Death of Domestic Employer 19 Parental Leave
4 Dismissed 8 Insolvency/Liquidation 12 Transfer to another Branch 16 Voluntary Severance Package
5 Contract Expired 9 Maternity/Adoption 13 Absconded 17 Reduced Work Time