Company letterhead

Date: _____

Confirmation

This is to confirm that the following sources of income were paid to [Name Surname] by [Company
name] during 1 January 2019 - 31 December 2019 for the working activity carried out in Moldova
based on the delegation agreement to Moldova No.__ dated_____.

Other income /
Gross salary Allowances Total Gross income
Month Payment date benefits
(Currency) (Currency) (Currency)
(Currency)
1 2 3 4 5 6=3+4+5
January dd/mm/yyyy
February dd/mm/yyyy
March dd/mm/yyyy
April dd/mm/yyyy
May dd/mm/yyyy
June dd/mm/yyyy
July dd/mm/yyyy
August dd/mm/yyyy
September dd/mm/yyyy
October dd/mm/yyyy
November dd/mm/yyyy
December dd/mm/yyyy
Total

(Name, position and signature

of the company responsible person)

(company stamp)