Employment Termination Verification Form

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Employment Termination Verification Form
(To be completed by employer)
SS#
Reports that he is no longer employed
at
EMPLOYER
ADDRESS
Please verify the following information for our records:
Last date worked:
Date final pay received:
Gross amount of final pay: $
Reason for termination:
Are maternity benefits being paid?
YES
NO
N/A
Are workers compensation benefits being paid?
YES
NO
N/A
Are unemployment benefits being paid?
YES
NO
N/A
Signature
Date
Title
Telephone #
Thank you for your time and attention.
Please return to Sandra Claessens by FAX at (724) 265-4105

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