Payroll / Status Change Notice Form - Duchesne County, Utah
ADVERTISEMENT
1
2Payroll / Status Change Notice
New Hire Change Separation
Routing: Payroll Personnel File (Original)
Effective Date of Change
Employee Name
LAST
FIRST
MIDDLE INITIAL
Employee/Payroll #Dept.
New Hire Information
Address
STREET
CITY
STATE
ZIP CODE
Telephone # (
)
Date of Birth
(for administrative use only)
Status: Full-Time Part-Time Temp Seasonal
New Employee Rate $
Job Title
Hours per Week______________
W-4 Attached? Yes No
Classification: Executive Occupational
Change(s) for Current Employee
ACTION(S)
FROM
TO
COMMENTS
Demotion
Department
FLSA Status
Job Title
Length of Service Increase
Merit Increase
Promotion
Reduction in Force
Re-evaluation of Current Job
Rehire
Resignation
Salary/Wage
Separation (see below)
Transfer
Other
Leave of Absence
/
/
/
/
BEGIN LEAVE
RETURN FROM LEAVE
Educational
Personal
Family/Medical Leave
Military
Other
Separation
/
/
SEPARATION DATE
LAST DAY WORKED
/
/
Voluntary Separation
Involuntary Separation
Reduction in Force
_______/_______/________
_________________
_______________
BENEFIT CANCELATION DATE
REIMBURSEMENT OWED TO COUNTY
FOR_
Additional Comments
Manager Signature:
Date:
HR Signature:
Date:
Payroll Signature:
Date:
11/2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal