I, _______________________________________________________, ID / Passport No. _________________________, received the following payment from my employer ______________________________ on (date) _____________________.

1. Wages (from ____________ to ____________) $_______________

inclusive of payment for the following:

(a) statutory holiday(s) (dates: )

(b) annual leave (from ____________________ to ____________________)

(c) sick leave (from ____________________ to ____________________)

(d) others (please specify) ________________________________________

2. Food allowance (from _____________ to ___________) $____________

3. Wages in lieu of notice $____________

4. Untaken annual leave pay ( days) $____________

5. Long service payment / severance payment $____________

6. Travelling allowance $____________

7. Payment in lieu of air-ticket / return air-ticket of $____________

_______________________ (Airline)

8. Others (a) ______________________ $____________

(b) ______________________ $____________

Signature of Helper Signature of Employer

(Name) : __________________ (Name) : ___________________

Witnessed by (if any) (Name): ________________________

^* delete where appropriate