I, _______________________________________________________, ID / Passport No. _________________________, acknowledge receipt of the reimbursement of processing fees from my employer ______________________________________________ on (date) _____________________ ^* in cash / by cheque / by bank autopay.

(a) Mandatory Insurance $____________

(b) Medical Examination Fee $____________

(c) Notarization Fee $____________

(d) Visa Extension Fee $____________
(e) Philippines Overseas Employment $____________

Administration (POEA) Fee

(f) Others $____________

Received by

(Name) : __________________________________________________

Witnessed by (if any)

(Name) : __________________________________________________

^* delete where appropriate