Sample Separation Notice - Free Download
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Sample Separation Notice
Date of Notice:
May 17, 2012
Date of Separation:
May 14, 2012
Employer Name:
ABC Company, Inc.
Employee Name:
John Smith
Employee Address:
123 Main Street, San Francisco CA 91234
Account Summary:
04.15.2012 $4,000.00
Prior Balance
04.23.2012 -$741.31
Reimbursement to Employee
05.17.2012 141.13
Final Contribution (for hours paid in 2
nd
Q)
$3,399.82
Current Balance
Expiration Date:
Expiration Date of Funds:
08.16.2012 (90 days from final contribution)
Your reimbursement account is being administered by:
Name:
Third Party Administrator, Inc.
Address:
TPA Boulevard, San Francisco CA 91234
Phone:
(415) 123-4567
