Model Werkgeversverklaring (NHG werkgeversverklaring 2024-1 2.0, geldig vanaf 01-03-2024) Instructions

Check this box when the fixed-term employment will be continued as a permanent (indefinite) employment contract after the current fixed-term ends.

Check this box when the employment will be continued for a new fixed term (specify the minimum number of months) after the current fixed-term ends.

Geef het minimale aantal maanden op waarvoor de vervolg- of vernieuwde arbeidsovereenkomst ten minste moet gelden nadat het bepaalde tijd contract eindigt. Fill only if 'Ja, voor bepaalde tijd (duur in maanden)' is 'Yes'.

Check this box when there will be no continuation or renewal of the employment contract after the current fixed-term ends.

Check this box if the employee is NOT a director or shareholder of the company.

Check this box if the employee IS a director or shareholder of the company (also provide the percentage of shares in the adjacent field).

Enter the percentage of company shares that the person (director or shareholder) owns. Fill only if 'Directeur/aandeelhouder — ja' is 'Yes'.

Enter the employee's residential address including street name, house number and any apartment or suite information.

Enter the employee's postal code followed by the city or town of residence.

Enter the employee's date of birth.

Enter the date the employee began employment with the company.

Enter the employee's current job title or function within the company.

Enter the employee's full legal name as used in official records.

Enter the employer's full legal or trading name as it appears on official records.

Enter the employer's street address including house number and any unit or building information.

Enter the employer's postal code followed by the city or town (for example: 1234 AB Amsterdam).

Enter the employer's KvK registration number exactly as issued by the Dutch Chamber of Commerce.

Check this box if, upon renewal, the employment conditions will not be changed (i.e., no changes to terms and conditions).

Check this box if, upon renewal, the employment conditions will be changed (i.e., there will be modifications to terms and conditions).

Geef een duidelijke toelichting op welke arbeidsvoorwaarden bij verlenging of vernieuwing zijn of worden gewijzigd en wat de impact daarvan is op het dienstverband of inkomen van de werknemer. Fill only if 'Worden bij vernieuwing de arbeidsvoorwaarden gewijzigd? - ja' is 'Yes'.

Check this box if the employee has a permanent (open‑ended) employment contract or is employed in a permanent position.

Check this box if the employee has a fixed‑term (temporary) employment contract or is appointed for a temporary position.

Enter the date on which the fixed-term or temporary appointment ends. Fill only if 'een arbeidsovereenkomst voor bepaalde tijd of is aangesteld in tijdelijke dienst tot' is 'Yes'.

Check this box if the employee’s income comes from a flexible employment relationship (e.g., on‑call, casual, or agency work).

Enter a short description of the flexible employment relationship that provides income (for example: on-call, substitute, agency work, including phase), or other relevant details. Fill only if 'inkomen uit een flexibele arbeidsrelatie nl.' is 'Yes'.

Enter the full name of the person who will sign this declaration (the signatory on behalf of the employer).

Enter the employee's gross annual salary (bruto jaarsalaris) as stated by the employer, i.e. the total yearly base salary before taxes and excluding overtime and benefits, in euros.

Enter a short description naming the source or nature of the other income for income row 10.

Enter the amount corresponding to the other income listed in row 10.

Enter the employee's gross holiday allowance amount in euros for the relevant period.

Voer het brutojaarlijkse bedrag in van de 13e maand (extra maandsalaris) dat de werknemer ontvangt, als onderdeel van het inkomen.

Enter the gross year-end (eindejaarsuitkering) bonus amount in euros for the employee for the indicated year.

Enter the total annual amount in euros of the structural (onregelmatigheid) allowance paid to the employee.

Enter the total amount in euros of regular/structural overtime pay received by the employee (over the relevant annual/reference period) to be included in the income calculation.

Enter the structural (recurring) commission amount for this employee — the recurring provision component of income to be reported for the reference period.

Enter the amount in euros for row 8: the structural flexible budget that is freely disposable and payable in cash to the employee.

Enter a short description of the other income source for income row 9 (e.g., type of allowance, bonus or benefit).

Enter the monetary amount for the other income on row 9 as a numeric value representing the total amount.

Vink aan wanneer de werkgever geen onderhandse (particuliere) lening aan de werknemer heeft verstrekt.

Vink aan wanneer de werkgever wél een onderhandse (particuliere) lening aan de werknemer heeft verstrekt.

Enter the date the private loan to the employee begins. Fill only if 'Onderhandse lening verstrekt (ja)' is 'Yes'.

Enter the total principal amount of the loan in euros. Fill only if 'Onderhandse lening verstrekt (ja)' is 'Yes'.

Enter the duration of the loan in months (number of months). Fill only if 'Onderhandse lening verstrekt (ja)' is 'Yes'.

Enter the monthly repayment amount for the loan in euros. Fill only if 'Onderhandse lening verstrekt (ja)' is 'Yes'.

Check this box if there is no probationary period for this employment.

Check this box if there is a probationary period for this employment.

Check this box if the probationary period has not elapsed (the probation is still in effect). Fill only if 'Is er sprake van een proeftijd? — ja' is 'Yes'.

Check this box if the probationary period has elapsed (the probation is completed). Fill only if 'Is er sprake van een proeftijd? — ja' is 'Yes'.

Check this box if no reorganization or measure has been announced that could affect the employee's employment or income.

Check this box if a reorganization or measure has been announced that could affect the employee's employment or income.

Explain how the announced reorganization or measure will affect the employee’s employment or income, including which measures are planned, whether employment will be reduced, suspended or terminated, any changes to working hours or salary, relevant dates and expected duration or extent of the impact. Fill only if 'Reorganisatie/maatregel aangekondigd - ja' is 'Yes'.

Enter the place (city or location) where the form is signed.

Enter the date on which the signatory signed the form.

Enter the full name of the person who signs this declaration on behalf of the employer.

Enter the full name of the person who can be contacted to verify the information on this form.

Enter the telephone number for the verification contact, including country and area code if applicable.

Check this box if there is no wage garnishment (loonsbeslag) or wage assignment (looncessie) affecting the employee.

Check this box if there is an active wage garnishment or wage assignment for the employee (and then complete the accompanying fields for amount, period and monthly deduction).

Enter the end date until which the wage garnishment or assignment applies. Fill only if 'Loonsbeslag of looncessie - ja' is 'Yes'.

Enter the monthly amount to be withheld from the employee's wages for the garnishment/assignment. Fill only if 'Loonsbeslag of looncessie - ja' is 'Yes'.