DEPARTMENTAL LETTERHEAD

FORM L

(G.O. 280(2))

	SARAWAK GOVERNMENT	File No .................................
	MALAYSIA	Date: + .................................

CONFIRMATION LETTER AND UNDERTAKING BY OFFICER

*DIRECTOR/MEDICAL SUPERINTENDENT/MEDICAL OFFICER IN CHARGE OF
*HOSPITAL/CLINIC

Sir,
This is to certify that the undermentioned is an officer serving in this office.
Name of Officer: ........................................................................................................................................................
1. C. No.: ..........................Salary Grade: ....................................Basic Salary:.......................................................

Appointment:	.......................................................................................................................................
Class of Ward Eligibility:	.......................................................................................................................................
Office Address:	.......................................................................................................................................
	.......................................................................................................................................

2. *The officer/wife/husband/mother/father/child of the officer whose particulars are as mentioned below seeks medical treatment.

Name: ....................................................................................................................................................

Relationship:........................................................................................................................................

3. This Department agrees to deduct from the salary of this officer to pay for hospital bill in respect of such treatment.

..................................................................		..................................................................
(Signature of Head of Department)		(Official Seal of Department)

Name: ..................................................................

Designation: .......................................................

Telephone No.: ..................................................

UNDERTAKING BY OFFICER ALLOWING DEDUCTION OF SALARY TO PAY FOR HOSPITAL BILL IN RESPECT OF TREATMENT RECEIVED

I, ....................................................................., am drawing a salary of RM ........................................
attached to the *Ministry/Department of .............................................................................................
is liable for the settlement of the amount claimed and hereby allow and authorise the Head of
Department to deduct my salary in settlement of the hospital fees charged in respect of my
treatment/the treatment of my family/mother/father* as follows:

Name: ..........................................................................................................................................................
Salary No.: .................................................................................................................................................
Relationship: .............................................................................................................................................

...................................................................
(Signature of Officer)

1. C. No.: ..................................................

cc	Salary Management Unit (Address) ....................................................................................
	Personal File of Officer ..........................................................................................................

Note:

The particulars above should be completed in full.
+This letter is valid for three months from date hereof.
*Delete whichever is inapplicable.