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[ ] How often is the pay received?
[ ] Daily [ ] Weekly [ ] Every 2 weeks [ ] Twice a month [ ] Monthly [ ] Other
[ ] What day of the week is the pay received?
[ ] Sunday [ ] Monday [ ] Tuesday [ ] Wednesday [ ] Thursday [ ] Friday [ ] Saturday
[ ] Does your company help pay for child care? If yes,
How much?
How often?
[ ] Does this individual have health insurance coverage? [ ] Yes [ ] No If yes,
complete the following information:
Insurance company name:
Certificate number: Effective date of coverage:
Persons included in coverage:
[ ] If the individual is no longer employed by you, complete the following information:
Reason for termination of employment:
[ ] Quit [ ] Fired [ ] Laid off [ ] Other:
Date the employment terminated:
Date final pay received:
Amount of gross income received during the last month of employment: $
If the employee quit, what was the reason given by the employee?
Thank you for your assistance in this matter. If you have any questions regarding this
form, please contact at
EMPLOYER, PLEASE SIGN BELOW AND RETURN USING THE ENCLOSED ENVELOPE OR
FAX TO_________________________________________.
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Company Name Name and Title of Person Completing Form Date
( )
Company Address Telephone Number
City State Zip Code
Distribution: Original(s) to employer
