Payroll/Status Change Form - Free Download
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Payroll/Status Change Form
Payroll/Status Change Form
Payroll/Status Change Form
[] New Hire [] Change [] Separation
Employee Information:
Effective Date of Change: Employee/Payroll # Social Security #
Employee Name : Department Telephone ( )
Last First
Address Date of Hire
Street Apt
Date of Birth
City State Zip
Employee Status: Position:
[] Exempt [ ] Non-Exempt [ ] Part-time [] 10 month position (perm) [] 10 month position (temp)
[] Hourly [ ] Salary [ ] Full-time
[] 12 month position (perm) [] 12 month position (temp)
[] FT Temporary ________________
# of months/wks/days
[] PT Temporary ________________
# of months/wks/days
Change(s) for Employee:
TYPE
OLD
NEW
COMMENTS
Address Change
Add Dependent
Marital Status
Benefit Change
Insurance Eligibility
Promotion/Demotion
Transfer
LOA
Resignation
Retirement
Rehire
Status Change
Re-evaluation of current
position
Annual Increase
Merit Increase
$
$
% increase
Supervisor Signature Date Manager Signature (if applicable) Date
_________________________________________________________________
Human Resources Signature Date Vice President for Finance & Administration Signature Date
President Signature Date Employee Signature Date
Payroll/Status Change Form Previous Page
Payroll/Status Change Form
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