Computation of Claims

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Name of Worker *

Name of Employer *

Monthly Wage *

Daily Wage

First Day of Work

Leave it blank if not applicable

Last Day of Work

Leave it blank if not applicable

Unpaid Wage

From

To

Number of Month(s)

Number of Day(s)

Total Unpaid Wage

Food Allowance

Monthly Food Allowance

Daily Food Allowance

Number of Months (Fa)

Number of Days (Fa)

Total Unpaid Food Allowance

Wages In Lieu of Notice

Number of Month(s) Inlieu

Number of Days(s) Inlieu

Total Inlieu

Annual Leave

From

Annual Leave

To

Annual Leave

Number of Year(s)

Number of Day(s) taken

Total Number of Leave(s)

Total AmountAnnual Leave Pay in PHP

Long Service / Severance Payment

Long Service = not less than 5 years of service

Severance Payment = not less than 2 years of service

Long ServiceSeverance Payment

No. of Year(s)

Total Amount

Others

Statutory Holiday Pay

Number of Day(s)

Total Statutory Holiday Pay

Rest Day Pay

Number of Day(s)

Total Rest Day Pay

Please do not fill in this field.

Migrant Workers Office Hong Kong is 5 mins away by walking from Admiralty Station (Hong Kong Island) Exit D

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