Term Form 8-2015
Hampshire College Notice of Termination Form - TERM
Employee Information
Last First Middle
Forwarding Address (if applicable)_____________________________________________________________________________
Street City State Zip
Position Title: ___________________________________ Last Day Physically Worked: ___________ Term Date: __________
Classification: Exempt Non-Exempt Faculty Casual Other ________________________
FTE: Scheduled Hours: Employment Cycle (number of months):
Reason for Termination
Assignment Complete ASC Involuntary/Performance INP Position Eliminated/Involuntary PEI
Retirement RET
Violation of Policy VIO
Voluntary VOL
Would you rehire?
Yes No - Provide comments below
(attach additional page if necessary)____________________________________________
Budget Manager/Supervisor Signature: Date: Close Vacated Position? Y N
Human Resources Office Processing
Employment Date: Date of Birth: Social Security Number:
Benefit Information
Vacation (see below for calculation)
Health Insurance
Life Insurance
Calculation as of date: ______________
Hours due to employee: _____________
Hours owed to College: _____________
Plan: _____________
End Date
end of month in which employee terminates
COBRA Notification
End Date - is last day of employment
Conversion Notification
Flexible Medical Benefit
Annual Election: $_____________
End Date - is last day of employment
Medical Reimbursement Continuation
Yes No
(if yes, employee must sign continuation form)
End Date last day of employment
Retirement Annuity
End Date -
is last day of employment
Supplemental Retirement
End Date - is last day of employment
Voluntary Dental
Voluntary Vision
End Date
end of month in which employee
End Date
end of month in which employee
Computer Club Amount owed to College: $ _______________________(amount due is deducted from last paycheck)
Vacation Reconciliation Calculation
Vacation Award
Current year Number of mos. to be worked
Hours earned per month
Hours earned per month
Number of mos. Vacation earned
( # of mos. from July)
Vacation hours earned
Vacation hours earned
Vacation hours used
Vacation hours owed or to be paid
_____________________________ ________________________________ ________________________________
Payroll/Benefits Mgr./Date A.V.P. for Human Resources/Date Dir. of Strategic Budgeting & Analysis/Date
Human Resource Office Process Date/Initial: _______________ Pay Cycle: EP MP Close Vacated Position? YES NO
Instructions: Please complete form and send to Human Resources Office for processing, include employee’s letter of resignation
MISSING INFORMATION WILL DELAY PROCESSING. This document is confidential and should be treated accordingly.
Distribution by HR: HR/Personnel File Payroll
(HR) Jobcode to be closed: ______________________