CONTRACTOR STATEMENT FOR SOCIAL SECURITY PURPOSES
TO THE CONTRACT OF MANDATE/ FOR PRVIDING SERVICES
 No. ............................ of ................................
CONTRACTOR PERSONAL DATA
1.	Surname: ...................................................................................................................
2.	Name(s): ............................................................................................................
3.	Date and place of birth: .........................................................................................
4.	Nationality: ...........................................................................................................
5.	Personal identity number (PESEL):

PLACE OF RESIDENCE FOR SOCIAL SECURITY PURPOSES 
1.	Place ..............................................................................................................
		-				
2.	Postal code
3.	Address ........................................ 
4.	Province ...........................................................................................................
5.	Country ............................................................................................................
ADDRESS FOR CORRESPONDENCE (if other than the place of residence)
1.	Place ..............................................................................................................
		-				
2.	Postal code
3.	Address ........................................
4.	Province ...........................................................................................................
5.	Country ...........................................................................................................

CONTRACTOR STATEMENT
I state that:
1.	I am/ am not* employed under any employment contract or equivalent agreement (regardless of the employer and the duration of the working time)
My gross monthly remuneration under the employment relationship is*:
-	at least the minimum wage,
-	less than the minimum wage.
I am / am not* on unpaid leave from ...................................... to ......................................
2.	I am/ I am not* covered by any age or disability pension scheme as a person performing home-based work or any work under a contract of mandate or agency from ………………….. to …………………..
My gross monthly remuneration for home-based work or work under a contract of mandate or agency is*:
-	at least the minimum wage,
-	less than the minimum wage.
3.	I am/ I am not* covered by any age or disability pension scheme as a person carrying out business activities. 
The basis for paying social security contributions under the business activities carried out is*:
-	at least the minimum wage,
-	less than the minimum wage.
4.	I am/ am not* paid any age or disability pension – social security no. ............................
5.	I have/ have not* been granted a ................... disability certificate for a period from ............................. to ............................. .
6.	I am/ I am not* a secondary education/ BA or MA student and I am under the age of 26.
7.	I am / am not* on maternity/parental* leave from ...................................... to ......................................
8.	I apply/ do not apply* to join the sickness insurance scheme on a voluntary basis. 
* Delete as appropriate
I state that all the information provided is in accordance with factual and legal circumstances and that I am aware of criminal liability for providing any information that is incorrect or for concealing any information.  
I undertake to notify the Customer in writing of any change in the contents hereof within 3 days thereof and I assume liability for failing to comply with this obligation. 
...................................................
(Date and signature of the Contractor)