Employee Status Change Form
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1EMPLOYEE STATUS CHANGE FORM
Date:
_______________________________________________ _____
Client Company:
_____________________________________________________
Employee Name:
_____________________________________________________
Change in Rate of Pay:
Change in Workers Comp Code:______
New Rate of pay: $__________
___ Per Hour
___ Bi-Weekly
___ Salary
___ Semi-Monthly
___ FT/PT
___ Monthly
Other Changes:
___
Change of Address:
____________________________________
Street Address
____________________________________
City
State
Zip
___
Change of Telephone:
____________________________________
Area Code
Telephone
___
Change in Marital Status
___ Single
___ Married ___ Other
___
Change in Number of Dependents (Explain in Detail)
____________
__________________________________________________________________
___
Additional Amount, if any withheld from Paycheck __________________
___
New W-4 Federal Withholding Deductions (Attach new W-4 form)
___
Re-hire Date if within 30 days of termination _______________________
___
Other (Explain in Detail) ______________________________________
___________________________
________________________
Employee’s Signature
Date
___________________________
________________________
Employer’s Signature
Date
Please fax completed form back to us at (706) 226-2352 or email to
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Parent category: Business