Payroll Status Change Form

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PAYROLL STATUS CHANGE FORM
Employee Name:
Effective Date:
Compensation review sources:
Source
Title
25%
50%
75%
Average:
New Employee:
Compensation Change:
From
To
Hourly Rate:
$ ____________
Hourly Rate:
$ ___________
$ ___________
Status:
Hourly
______ Salary
______ Rate %:
_________%
_________%
Department: ________________________________
Status:
Hourly
______ Salary
______
Supervisor: _________________________________
Reason: ___________________________________
(see list below)
Terminate Employee:
Transfer Employee:
Reason: __________________________________
From Department: _______________________
(see list below)
(see list below)
To Department:
_______________________
Eligible for Rehire:
Yes _____ No _____
Supervisor/Team Manager Approval and Comments:
Department/Unit Manager Approval and Comments:
Executive Staff/Division Manager Approval and Comments:
CEO Approval and Comments:
Reasons:
Budget Reduction
Layoff
Promotion
Cost of Living
Night Shift Bonus
Retirement
Demotion
Night Shift Removal
Transfer
Deceased
None Specified (include comments)
Voluntary (include comments)
Involuntary (include comments)
Performance Review
Employee Services Use Only:
Change Recorded : ____________
Comments: ______________________________________
4272W165rev03_06-23-10_form_payroll_change.xlsx
4272W165rev03_06-23-10_form_payroll_change.xlsx

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