A form for the employee to sign acknowledging receipt of the policies. Following are samples of these provisions.Here is a sample policy acknowledgment receipt that you can use when employees need to acknowledge their receipt and understanding of a policy. How to fill out the Final Paycheck Acknowledgment Form? We'll show you how with 5 acknowledgment email reply samples and a completely customizable template. I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she signed the foregoing document:. 1. Enter the case name and case number at the top of the form.