Golden Dragon System Int’l Corp.

22 General Wood St., SFDM, QC

MATERNITY BENEFIT ACKNOWLEDGEMENT RECEIPT AND AUTHORITY TO DEDUCT

Employee Information

Employee Name: Date:

Employee No: Position:

Mobile Number: Email Address:

Department:

Present Address:
Permanent Address (if
different from above):

Person to Contact in Contact No.:

case of Emergency: Relationship:

This is to acknowledge receipt of the amount of FIFTY-FIVE THOUSAND SIX HUNDRED FORTY-ONE & 03/100
PESOS ONLY ( P55, 641.03) equivalent to my SSS maternity leave benefit for the period from August 24, 2022 to
November 9, 2022, which amount was advanced to me by my employer, Golden Dragon System Int’l Corp.
I hereby also acknowledge and authorize a deduction from my SSS maternity leave benefit the amount of Two
Thousand Two Hundred Forty-Three & 77/100 Pesos Only (P2, 243.70) as stated in the attached salary
differential computation which includes my premium contributions and loan amortizations to respective
government agencies for the duration of my maternity leave.

Relative to this, I undertake to submit all the documentary requirements as discussed with me and listed
hereunder, no later than two (2) weeks from the end of my maternity leave.

SSS Obstetrical (OB} History Form accomplished by the attending physician

Certified True Copy of Child’s birth or fetal death certificate duly registered with the Local Civil
Registrar
Certified True Copy of Operating Room Record/Surgical Memorandum (for caesarian delivery)
Dilatation and Curettage (D&C) Report/Histopathological Report (for incomplete miscarriage)
Pregnancy test before and after miscarriage/Ultrasound report indicating proof of pregnancy (for
complete miscarriage)

In this regard, I hereby assign to my employer the maternity benefits equivalent to the amount stated above as
soon as my maternity leave entitlement form the SSS is remitted my the said government agency.

Finally, I understand that if I submit any falsified documents and/or I fail to comply with the submission of any
of the required document which results in the denial of my claim, I authorize my employer to deduct the stated
amount from my salary or any receivables from the Company under such terms and conditions as may be
allowed under the existing law. I further acknowledge that any such deduction is without prejudice to any
action my employer may take against me I accordance with the Company Code of Conduct

__________________________________ ___________________
Employee Signature over Printed Name Date Signed