Payroll/status Change Form

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Johnson Employer Support Services
Payroll/Status Change Form
Please Print Clearly
Fax to 870-862-3706
Effective Date of Change ____/____/____
New Hire
Rehire
Change
Termination
New Client
Employee Name _______________________________________________________________________ Client Hire Date
Social Security # ________-______-_________
Client_____________________________________ _____________
New Hire Information
Address _______________________________________City ___________________________ St ____ Zip ___________
Telephone (
)___________________________
Date of Birth ____/____/_____
Status:
Full-Time
Part-Time
Temporary, How long? ________ Wage/Salary $_______ Per ________
Fed WH ______________ State WH ______________ Job Title ___________________________ WC Code__________
Attached:
W-4
State Withholding
I-9 (IDs Checked
___________
_________)
Handbook Receipt
Changes for Current Employees
Type
From
To
Comments
Address Change
Change of Insurance
Job Title
Department Change
Merit Wage Increase
Length of Service Increase
Wage Decrease
Other
Leave of Absence
Begin Leave ____/____/_____
Educational
Personal
Family/Medical Leave
Return____/____/_____
Short Term Disability
Long Term Disability
Other
Termination
Termination Date ____/____/_____ Last Day Worked ____/____/_____ Last Pay ____/____/_____
Quit
Layoff (Subject to recall)
Notice of COBRA Rights ____/____/_____
Discharged
Not Eligible for Rehire
COBRA Election
No
Yes
Comments
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Does the employee need a Skylight pay card?
Yes
No___________________________________________________
Employee Signature (Optional) ___________________________________________________ Date ____/____/_____
Supervisor Signature ____________________________________________________________ Date ____/____/_____
JESS Document Handling Payroll
HR
Management
Files
New Hire #_________________________

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