(This letter serves to record payments made for and on behalf of an employee while on maternity leave for benefit contributions such as Medical Aid and Retirement Fund)
I, ___________________________________________ hereby acknowledge that I am indebted to (COMPANY NAME) for an amount of R ________________________ (state amount in words) for contributions made on my behalf for Medical Aid and/or Retirement Fund for the period of __________________ (Date of commencement of Maternity Leave) to _________________________ (Date Maternity Leave ends). The total sum of contributions being R __________________________.
I confirm that I have agreed that (COMPANY NAME) undertakes to continue contributing towards the Company’s Medical Aid and/or Retirement Fund on my behalf in terms of the (COMPANY NAME)’s Maternity Leave Policy, during my Maternity Leave period.
I hereby agree to work for (COMPANY NAME) for a period of 6 months after my return from Maternity Leave in order to fulfill my obligation to this agreement.
Should I leave (COMPANY NAME)’s services for any reason whatsoever within a period of 6 months after returning to work, I agree to repay the Company a pro rata portion of the Maternity Pay according to the pro rata formula below:
Work back period: % Repayment due
0 Months 100%
1 Month 85%
2 Months 70%
3 Months 50%
4 Months 35%
5 Months 20%
6 Months 0%
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Employee Signature Date
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Line Manager Signature Date
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Human Resources Signature Date
