The payment to be made to the employee for the leave is: $_______ subject to deduction of income tax/after deduction of income tax (strike out where not applicable) The payment will be made to the employee on: ___/___/20___ Signature of employee: ________________________________________ Date signed: ___/___/20___ Name of employer representative: ________________________________________ Signature of employer representative: ________________________________________ Date signed: ___/___/20___ Include if the employee is under 18 years of age: Name of parent/guardian: ________________________________________ Signature of parent/guardian: ________________________________________ Date signed: ___/___/20___
The payment to be made to the employee for the leave is: $_______ subject to deduction of income tax/after deduction of income tax (strike out where not applicable) The payment will be made to the employee on: ___/___/20___ Signature of employee: ________________________________________ Date signed: ___/___/20___ Name of employer representative: ________________________________________ Signature of employer representative: ________________________________________ Date signed: ___/___/20___ Include if the employee is under 18 years of age: Name of parent/guardian: ________________________________________ Signature of parent/guardian: ________________________________________ Date signed: ___/___/20___