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GENERAL FORM No.

5 DAILY WAGE PAYROLL Sheet______ of______ Sheets


____________________________________________________
Project
Agency______________________________ Period______________________________

COMMUNITY TAX CERTIFICATE


NAME OCCUPATION NUMBER RATE PER AMOUNT PAID SIGNATURE OF
OF DAYS DAY THUMBMARK
WORKED NUMBER DATE PLACE OF ISSUE

1. 1.
2. 2.
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4. 4.
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CERTIFIED: Approved for Payment: CERTIFIED:


Each person whose name on this roll had rendered services Each person whose name appears on the above roll has been
for the time stated. paid the amount stated opposite his name after identifying
him.

________________________________________________________ ________________________________________________________ ________________________________________________________


Name and Signature of a Forman/Superior Name and Signature of a Forman/Superior Name and Signature of Disbursing Officer