Important: If this is a temporary
separation or if
you expect the leased employee to return to work for you, do not complete this form.
Employee Status Changes
Employee Termination: Required for State Unemployment Purposes
Please answer YES or NO to the following
Is employee eligible for re-hire with Client?
Did employee sign a separation and release agreement?
Upon separation did you report or will you be reporting payroll
wages for the employee?
(Note: Wages must be reported to your Payroll Specialist.)
I certify that my statements are true and correct