NATIONAL AGENCY FOR EMPLOYMENT

Employment agency for the county | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | / Bucharest

DECLARATION

the unemployment insurance system to ensure individuals performing work-related income other than salary, which is due to individual contributions to unemployment insurance, according to art. Article III. (2) of the Emergency Ordinance no. 58/2010 amending and supplementing L egii no. 571/2003 on Fiscal Code and other financial and fiscal measures  

No. | _ | _ | _ | _ | _ | The day | _ | _ | month | _ | _ | year | _ | _ | _ | _ | *

Name and surname of the insured: | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ |

Personal identification number (PIN): | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ |

Home address or residence:

Location: | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ |

Street: | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ |

No. | _ | _ | Block | _ | _ | Scale | _ | _ | Floor | _ | _ | Bridal | _ | _ | _ | _ |

Post Office: | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ |

County: | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | / District: | _ | _ |

Phone: | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ |

ID: Series: | _ | _ | _ | no. | _ | _ | _ | _ | _ |

Declaration on achieving work-related income other than salary, hereinafter work-related income, which is due to individual contributions to unemployment insurance, according to art. Article III. (2) of the Emergency Ordinance no. 58/2010 amending and supplementing Law no. 571/2003 on Fiscal Code and other financial and tax measures:

I hereby declare that achieve work-related income as provided below, starting with:

day | _ | _ | month | _ | _ |, year | _ | _ | _ | _ |

1. Work-related income realized:

- Net income **:

- | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | USD

- The quality of the insured income realized: __________________________

- Source of income: __________________________

1. Average gross salary used to substantiate the state social insurance budget law approved by the state social insurance budget, 'the average gross salary:

| _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | USD

1. Base of individual contribution to unemployment insurance ***:

| _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | USD

1. Individual contribution rate to unemployment insurance, according to legal provisions:

| _ | _ |, | _ | _ |%

1. The amount representing individual contribution to unemployment insurance due under this statement: ****:

| _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | USD

1. Payment period for individual contribution to unemployment insurance due under this Declaration shall be by the 25th of the month for the previous month in which work-related income.
2. Individual contribution to unemployment insurance due under this Declaration shall be paid into account no.: | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ |, opened at the Treasury on behalf of the Agency for Employment of the county | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | / Bucharest.
3. Payment of individual contribution to unemployment insurance due under this declaration may be made in cash at the cashier for Employment Agency in whose jurisdiction the insured has established residence and by postal or other means of payment, conditions the law.

1. Rights of the insured:

a) to receive unemployment benefits under Law no. 76/2002 on unemployment insurance system and employment stimulation, as amended and supplemented;

b) pay periods for which individual contribution to unemployment insurance contribution period is the unemployment insurance system.

1. Insured obligations:

a) to make this statement only once, until the 25th of the month for the previous month that has made work-related income, the Agency for Employment in whose jurisdiction the residence is established;

b) to update this declaration within 14 days from the date of change in the amount of work-related income by filing a new declaration, stating the amount of work-related income made on each source of income;

c) where not work-related income, notify this agency for employment in whose jurisdiction the residence is set within 3 working days after the occurrence of this situation;

d) pay individual contribution to unemployment insurance in the period specified in paragraph 11 of this statement.

1.For unpaid individual contribution to unemployment insurance in the period specified in paragraph 11 of this declaration, is due to interest and penalties under the law.

1. This statement is debt and becomes enforceable after the claims included in this budget are due by law.

Insured declares its responsibility, under penalty under the Penal Code for making false statements, that the data contained in this statement true.

* To be completed by the employment agency in whose jurisdiction the insured has established the residence.

** To be completed properly for each work-related income realized.

*** Is determined by adding net income made, but no more than the equivalent of five times the average gross wage in the economy set out in paragraph 7 of this statement.

**** Is determined by applying the rate provided in section 9 of this statement on the basis of calculation provided in section 8 of this statement. If the average gross salary changes provided in section 7 of this statement or individual contribution rate to unemployment insurance, in paragraph 9 of this statement, the amount of amount of individual contribution to unemployment insurance due under this declaration is be made ​​taking into account the new amount of average gross wages and / or individual contribution rate of new unemployment insurance.