Request For Information On Termination Of Employment
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EMPLOYEE NAME: ________________________________________
SOCIAL SECURITY #: _________________________
I herewith give consent to my present/former employer to release the information as applicable.
Yo doy autorización para que mi empleador presente/anterior facilite la información como aplique.
Với mẫu đơn này, tôi cho phép người chủ hiện tại/người chủ trước đây tiết lộ tin tức cần thiết cho trường hợp của tôi.
Signature of Employee/Firma de Empleado/
Date/Fecha/Ngày
Telephone Number/Número Telefónico/
Chữ ký của Nhân Viên
Số Điện Thoại
TO BE COMPLETED BY EMPLOYER
(For instructions on how to complete this section, please see back of this form.)
Business Name: ____________________________________________
Address: _________________________________________________
Telephone Number: _________________________________________
1. When did he/she start working for your company/organization?
Start date: _____________ End date: _______________ Last day of work: ________________
2. Reason for termination:
Medical leave
Expected date of return: _______________
Temporary employment
Other: _________________________________________________
3. Is he/she eligible for rehire?
Yes
No
If yes, when? _______________
4. Date final check issued: _______________
Gross amount: $ __________
What were the total earnings paid in the last month of employment? $ ___________
5. Does employee have group health insurance coverage?
Yes
No
If yes, Name of insurance company: ___________________________ When will insurance stop? _____________
Can the group health insurance coverage be converted to an individual health plan?
Yes
No
6. Are there any outstanding benefits or pay due to the employee in the future?
Yes
No
If yes, identify type of benefit: ________________________________________________
When will it be issued? ______________________
Balance due: $ _______________
Print Name
Signature of Employer
Title
Date
Telephone Number
For Official Use Only
RECORD ID #: _____________________
SC 549-B (E/Sp/V) – 01/08
Scan: F2/F9
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Parent category: Business