一、本人(国籍：菲律宾，护照号码：     )确实了解来华工作最长可达三年，惟是否能展延到三年，系由雇主与本人就本人工作表现及业务需要，协议是否展延。来华工作应领工资、加班费等如适用劳动基准法，则依该法规定办理；如不适用则于劳动契约中订定。

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、本人来华前在劳工输出国所发生之全部费用如下：

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

(一)中介费：菲律宾币     PESO(NT$：     元)。

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

(二)规费及其它费用(仅列举常见项目，请依实际支付状况增删填写)：

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、前项费用本人于来华前在劳工输出国已缴纳菲律宾币     PESO(NT$:      元)；不足部分经向     (债权人)借贷含利息共菲律宾币      元(NT$      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、来华工作有关之借款：本人除同意以下借款于来华后代为收取外(请详列债权人、项目用途及金额)，并未同意任何其它在台湾代为收取之费用：

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:

※注意事项：来华工作有关之借款指凡劳工安家费、私人借款及向外国人力中介公司、银行借款等款项，并经劳工同意在华代收之相关费用。未列于此切结书之其它款项，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、本人确实了解以下台湾相关收费规定【法令如有修正，应依修正后之规定办理】：

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)服务费： (1) Service Fees:

1.第一年每月最高为NT$1,800元、第二年每月最高为NT$1,700元、第三年每月最高为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.但曾来华工作二年以上，因聘雇关系终止或聘雇许可期间届满回国后再来华工作，并受雇于同一雇主之外国人：每月最高均为新台币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.人力中介公司不得预先收取超过三个月之服务费。

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

(二)规费【如有修正，依修正后之规定办理】及其它费用：

 (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.健保费：每月NT$       元。Health Insurance Fee: NT＄____ per month.

2.劳保费：每月NT$      元(依规定仅渔业或劳工人数在五人以上之事业单位须强制参加劳保，五人以下者【如家庭类】并未强制参加劳保)。

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.居留证费：每年NT$      元。     Residence Permit Fee: NT＄______ per year.

4.所得税：前____ 个月每月____  、第____个月起每月____  。

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

(1)同一年度(1/1～12/31)在华居留未满183天(约6个月)者：所得税=总所得╳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)在华居留183天以上者：所得税=(总所得-免税额-标准扣除额-薪资扣除额)╳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)上年度在华居留183天以上者，下年度不论在华居留天数，均准用前项规定：所得税=(总所得-免税额-标准扣除额-薪资扣除额)╳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)其它费用：(请依实际约定详列费用项目及金额)

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

六、本人已充分了解来华工作每月约定工资为新台币      元。

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

本切结书经本人确认无误。I HEREBY CONFIRM THIS AFFIDAVIT AS ACCURATE.

切结人签名Affiant：  (Signature)

外国人护照号码(务必填写)Affiant’s Passport Number: _____(REQUIRED)

日期Date:

本切结书所载事项经本公司查证属实。

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

认可编号Verification Code Number:

外国人力中介公司名称(英文)： Foreign Human Resources Agency:  (English Name)

负责人或代表人签名：Person In Charge/Representative of the Agency:(Signature)

日期Date:

劳工输出国主管部门验证：

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

日期Date:

本切结书所载事项经本机构查证属实。

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

台湾私立就业服务机构：Private Employment Service Agency In TAIWAN:

许可证号Permission Code Number:

负责人或代表人签名Person-In-Charge/Representative:  (Signature)

日期Date:

本人(雇主)确实了解除本切结书或法令另有规定外，不得自外国人薪资中扣留任何费用。

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: (盖章或签名) (Stamp/Signature)

负责人或代表人签名Person-In-Charge/Representative: (Signature)

 日期Date:

备注：Note:

1.    本切结书确实由受雇外国劳工本人填写及签名，经外国人力中介公司负责人或代表人签名，并由该国主管部门验证。

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.本切结书经验证后，由外国劳工携带来华交予雇主，作为雇主办理申请聘雇许可之用。

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.外国劳工在缴交各项费用时，请务必向中介公司索取收据，俾有争议时，提供查处之用。

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.如外国人力中介公司或台湾人力中介公司有未依规定收取费用或雇主有未依契约给付薪资等情事，外国人得向台湾行政院劳工委员会提出检举，该会受理检举后，会予以保密，并保护外国人在台之工作权益。检举专线：

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.本切结书如有伪造或填写不实者，愿依就业服务法相关规定接受处分。

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.