Form NI 184
Statement of Contributions Paid/Due
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Clear Form
Employer Information
Employer's Trade Name
Address
Street Address
City / District / County
Employer Registration Number
Telephone Number
Phone
Contributions Period
From
To
Number of Weeks in Period
Employee Contribution Details
N.I. Number
Employed Person or Unpaid Apprentice
Date of Birth
Date Employed
Last Date Worked
Salary for period
Week 1
Week 2
Week 3
Week 4
Week 5
Total
Add Employee
Total Number of Employees
Total Value of Contributions
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