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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.

Personal Information
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