一、本人(國(guó)籍：菲律賓，護(hù)照號(hào)碼：     )確實(shí)了解來(lái)華工作最長(zhǎng)可達(dá)三年，惟是否能展延到三年，系由雇主與本人就本人工作表現(xiàn)及業(yè)務(wù)需要，協(xié)議是否展延。來(lái)華工作應(yīng)領(lǐng)工資、加班費(fèi)等如適用勞動(dòng)基準(zhǔn)法，則依該法規(guī)定辦理；如不適用則于勞動(dòng)契約中訂定。

I (Nationality: PHILIPPINE; Passport Number:       ) have fully understood that the period in which I am permitted to work in the territory of the Republic of China (hereinafter TAIWAN) shall not exceed three (3) years, that whether my term of employment will be extended to three (3) years depends upon whether my Employer and I will agree to make such extension taking into account my working performance and my Employer’s business needs, and that those matters including inter alia the regular and overtime wage/salary to be received by me for my work in TAIWAN shall be governed by the Labor Standards Act if applicable or by the Labor Contract if the said Labor Standards Act is inapplicable.

二、本人來(lái)華前在勞工輸出國(guó)所發(fā)生之全部費(fèi)用如下：

All the expenses incurred by me in the Labor-Exporting Country prior to my arrival in TAIWAN to work are listed as follows:

(一)中介費(fèi)：菲律賓幣     PESO(NT$：     元)。

Placement Fee:     dollars in the currency of the Labor-Exporting Country (NT＄     ).

(二)規(guī)費(fèi)及其它費(fèi)用(僅列舉常見(jiàn)項(xiàng)目，請(qǐng)依實(shí)際支付狀況增刪填寫)：

Regulation Fees and Other Fee(s) (Listed hereinafter in the table are merely the common items, which shall be deleted/added according to the actual payments made):

三、前項(xiàng)費(fèi)用本人于來(lái)華前在勞工輸出國(guó)已繳納菲律賓幣     PESO(NT$:      元)；不足部分經(jīng)向     (債權(quán)人)借貸含利息共菲律賓幣      元(NT$      元)。

Among the expenses as referred to in Article 2, I have paid _____ dollars in the currency of the Labor-Exporting Country (NT＄     ) prior to my arrival in TAIWAN, and as for the rest ______(Creditor) has made to me a loan with interest totaling _____ dollars in the currency of the Labor-Exporting Country (NT＄     ).

四、來(lái)華工作有關(guān)之借款：本人除同意以下借款于來(lái)華后代為收取外(請(qǐng)?jiān)斄袀鶛?quán)人、項(xiàng)目用途及金額)，并未同意任何其它在臺(tái)灣代為收取之費(fèi)用：

Loan(s) Related to Work in TAIWAN:  Except for the following loan(s) that is/are agreed by me to be collected on behalf of the creditor(s) in TAIWAN (please specify in detail the creditor(s), the item(s), the purpose(s), and the amount thereof), I have not agreed to any other loan(s) whatsoever to be so collected in TAIWAN:

※注意事項(xiàng)：來(lái)華工作有關(guān)之借款指凡勞工安家費(fèi)、私人借款及向外國(guó)人力中介公司、銀行借款等款項(xiàng)，并經(jīng)勞工同意在華代收之相關(guān)費(fèi)用。未列于此切結(jié)書之其它款項(xiàng)，任何人不得代扣或代收。

※Note: Loan(s) related to work in TAIWAN refer(s) to expenses including inter alia the worker’s family allowance, private loan(s), and loan(s) borrowed from foreign human resources agency and from banks, as agreed by the worker to be collected on behalf of the creditor(s) in TAIWAN  As to any other expense whatsoever that is not listed herein, no one is permitted to withhold or collect on behalf of the creditor(s).

五、本人確實(shí)了解以下臺(tái)灣相關(guān)收費(fèi)規(guī)定【法令如有修正，應(yīng)依修正后之規(guī)定辦理】：

I have fully understood the following relevant laws and regulations governing the expenses in TAIWAN (should there be any change in the relevant laws and/or regulations, the changed laws and/or regulations shall govern these expenses):

(一)服務(wù)費(fèi)： (1) Service Fees:

1.第一年每月最高為NT$1,800元、第二年每月最高為NT$1,700元、第三年每月最高為NT$1,500元。

The highest monthly payment is NT＄1,800 for the First (1st) Year, NT＄1,700 for the Second (2nd) Year, and NT＄1,500 for the Third (3rd) Year.

2.但曾來(lái)華工作二年以上，因聘雇關(guān)系終止或聘雇許可期間屆滿回國(guó)后再來(lái)華工作，并受雇于同一雇主之外國(guó)人：每月最高均為新臺(tái)幣NT$1,500元。

However, as for the Foreign Worker who has worked in TAIWAN for more than two (2) years, has returned to the Labor-Exporting Country at the expiration of the employment relationship or of the Employment Permit, and comes back to TAIWAN to work for the same Employer, the highest monthly payment is NT＄1,500 for all three years.

3.人力中介公司不得預(yù)先收取超過(guò)三個(gè)月之服務(wù)費(fèi)。

No Human Resources Agency may charge in advance for more than three (3) months’ Service Fees.

(二)規(guī)費(fèi)【如有修正，依修正后之規(guī)定辦理】及其它費(fèi)用：

 (2) Regulation Fees (should there be any change in the relevant laws and/or regulations, the changed laws and/or regulations shall govern the Regulation Fees) and Other Fee(s):

1.健保費(fèi)：每月NT$       元。Health Insurance Fee: NT＄____ per month.

2.勞保費(fèi)：每月NT$      元(依規(guī)定僅漁業(yè)或勞工人數(shù)在五人以上之事業(yè)單位須強(qiáng)制參加勞保，五人以下者【如家庭類】并未強(qiáng)制參加勞保)。

Labor Insurance Fee: NT＄_____ per month (according to the relevant laws and regulations, only fishery or business entities with five (5) or more employees are required to participate in Labor Insurance; business entities with less than five (5) workers (e.g., family category) are not so required).

3.居留證費(fèi)：每年NT$      元。     Residence Permit Fee: NT＄______ per year.

4.所得稅：前____ 個(gè)月每月____  、第____個(gè)月起每月____  。

Income Tax: ____ per month for the first ___ months, and _____ per month from the ___ month.

(1)同一年度(1/1～12/31)在華居留未滿183天(約6個(gè)月)者：所得稅=總所得╳20%。

(a)   For those who stay in TAIWAN for less than one hundred and eighty-three (183) days (about six (6) months) in the same year (January 1st to December 31st), the Income Tax equals 20% of the Total Income.

(2)同一年度(1/1～12/31)在華居留183天以上者：所得稅=(總所得-免稅額-標(biāo)準(zhǔn)扣除額-薪資扣除額)╳6%。

For those who stay in TAIWAN for one hundred and eighty-three (183) days (about six (6) months) or more in the same year (January 1st to December 31st), the Income Tax equals 6% of the Total Income as deducted of the Non-Taxable Amount, the Standard Deduction Amount, and the Wage/Salary Deduction Amount.

(3)上年度在華居留183天以上者，下年度不論在華居留天數(shù)，均準(zhǔn)用前項(xiàng)規(guī)定：所得稅=(總所得-免稅額-標(biāo)準(zhǔn)扣除額-薪資扣除額)╳6%。

For those who stay in TAIWAN for one hundred and eighty-three (183) days or more in the first year, the Income Tax for the next year shall be calculated in accordance with the preceding subparagraph (6% of the Total Income as deducted of the Non-Taxable Amount, the Standard Deduction Amount, and the Wage/Salary Deduction Amount) irrespective of the days of stay in TAIWAN in the said next year.

(三)其它費(fèi)用：(請(qǐng)依實(shí)際約定詳列費(fèi)用項(xiàng)目及金額)

Other Expenses (please list in detail the actually agreed items and amounts of the expenses):

六、本人已充分了解來(lái)華工作每月約定工資為新臺(tái)幣      元。

I have fully understood that the agreed monthly wage/salary for my work in TAIWAN is NT＄_____

本切結(jié)書經(jīng)本人確認(rèn)無(wú)誤。I HEREBY CONFIRM THIS AFFIDAVIT AS ACCURATE.

切結(jié)人簽名Affiant：  (Signature)

外國(guó)人護(hù)照號(hào)碼(務(wù)必填寫)Affiant’s Passport Number: _____(REQUIRED)

日期Date:

本切結(jié)書所載事項(xiàng)經(jīng)本公司查證屬實(shí)。

THIS COMPANY HEREBY VERIFIES THE CONTENTS CONTAINED IN THIS AFFIDAVIT AS TRUE.

認(rèn)可編號(hào)Verification Code Number:

外國(guó)人力中介公司名稱(英文)： Foreign Human Resources Agency:  (English Name)

負(fù)責(zé)人或代表人簽名：Person In Charge/Representative of the Agency:(Signature)

日期Date:

勞工輸出國(guó)主管部門驗(yàn)證：

Verification By The Competent Authorities Of The Labor-Exporting Country:

日期Date:

本切結(jié)書所載事項(xiàng)經(jīng)本機(jī)構(gòu)查證屬實(shí)。

THIS ORGANIZATION HEREBY VERIFIES THE CONTENTS CONTAINED IN THIS AFFIDAVIT AS TRUE.

臺(tái)灣私立就業(yè)服務(wù)機(jī)構(gòu)：Private Employment Service Agency In TAIWAN:

許可證號(hào)Permission Code Number:

負(fù)責(zé)人或代表人簽名Person-In-Charge/Representative:  (Signature)

日期Date:

本人(雇主)確實(shí)了解除本切結(jié)書或法令另有規(guī)定外，不得自外國(guó)人薪資中扣留任何費(fèi)用。

I (Employer) HAVE FULLY UNDERSTOOD THAT I SHALL NOT WITHHOLD ANY EXPENSES/FEES WHATSOEVER FROM THE WAGE/SALARY OF THE FOREIGN WORKER EXCEPT AS OTHERWISE STIPULATED BY THIS AFFIDAVIT OR LAWS OR REGULATIONS.

雇主Employer: (蓋章或簽名) (Stamp/Signature)

負(fù)責(zé)人或代表人簽名Person-In-Charge/Representative: (Signature)

 日期Date:

備注：Note:

1.    本切結(jié)書確實(shí)由受雇外國(guó)勞工本人填寫及簽名，經(jīng)外國(guó)人力中介公司負(fù)責(zé)人或代表人簽名，并由該國(guó)主管部門驗(yàn)證。

This Affidavit shall be personally filled out and signed by the employed Foreign Worker, and shall be thereafter signed by the Person In Charge or Representative of the Foreign Human Resources Agency in person at the office of the Competent Authorities of the Labor-Exporting Country for authentication.

2.本切結(jié)書經(jīng)驗(yàn)證后，由外國(guó)勞工攜帶來(lái)華交予雇主，作為雇主辦理申請(qǐng)聘雇許可之用。

The Foreign Worker shall bring this Affidavit as so authenticated to TAIWAN to be handed over to his/her Employer for the purpose of the Employer’s application for Employment Permit.

3.外國(guó)勞工在繳交各項(xiàng)費(fèi)用時(shí)，請(qǐng)務(wù)必向中介公司索取收據(jù)，俾有爭(zhēng)議時(shí)，提供查處之用。

The Foreign Worker is advised and required to demand from the Foreign Human Resources Agency the receipts for the various expenses paid, which receipts may serve as the basis for resolution of any possible controversies.

4.如外國(guó)人力中介公司或臺(tái)灣人力中介公司有未依規(guī)定收取費(fèi)用或雇主有未依契約給付薪資等情事，外國(guó)人得向臺(tái)灣行政院勞工委員會(huì)提出檢舉，該會(huì)受理檢舉后，會(huì)予以保密，并保護(hù)外國(guó)人在臺(tái)之工作權(quán)益。檢舉專線：

Should the Foreign Human Resources Agency or the Human Resources Agency in TAIWAN fail to charge fees in accordance with the applicable laws and regulations or should the Employer fail to pay the wage/salary in accordance with the Labor Contract, the Foreign Worker may file a complaint to the Council of Labor Affairs of Executive Yuan, the Republic Of China, which will treat the complaint with confidentiality and protect the rights and benefits of the Foreign Worker in TAIWAN  The special lines for complaints are:

5.本切結(jié)書如有偽造或填寫不實(shí)者，愿依就業(yè)服務(wù)法相關(guān)規(guī)定接受處分。

Should the Affidavit be forged or should there be any falsity of the contents herein, the Affiant is subject to relevant discipline or punishments in accordance with the relevant provisions of the Employment Services Act.