I, _______________________________________________________, ID / Passport No. _________________________, acknowledge receipt of payment of the following items from my employer ______________________________ on (date) _____________________ ^* in cash / by cheque / by bank autopay.

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 ____________) $_______________

Received by

(Name) : __________________________________________________

Witnessed by (if any)

(Name) : __________________________________________________

^* delete where appropriate