Simple template for salary notice needed

I need a template/document with the outline as the document shows. I need to be able to add the text which you see. It has to be an EXACT copy with same font.

Basically the documet just needs to get copied and I need to be able to use the design for future salaries.
The attached picture is the the text that has to be on the finished document.(the pink bits of paper shows what should be adjusted)

Thanks for your intrest in working with me.

Please Write "Salary" in subject line when giving an offer. If not its disregrded.