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    Form Employment Termination (631) - 2

    Uploaded by

    Mark Veeder
    This document is an employment termination form used by the Department of Workforce Services to collect information about an employee's termination, including employer details, employment history, reason for leaving, final pay and benefits. The form requires signatures from both the employer and employee and is to be returned to the Department of Workforce Services.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Form Employment Termination (631) - 2

    Uploaded by

    Mark Veeder
    206 views1 page
    This document is an employment termination form used by the Department of Workforce Services to collect information about an employee's termination, including employer details, employment history, reason for leaving, final pay and benefits. The form requires signatures from both the employer and employee and is to be returned to the Department of Workforce Services.

    Original Description:

    Employment termination form

    Original Title

    Form Employment Termination (631)-2

    Copyright

    © © All Rights Reserved

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    This document is an employment termination form used by the Department of Workforce Services to collect information about an employee's termination, including employer details, employment history, reason for leaving, final pay and benefits. The form requires signatures from both the employer and employee and is to be returned to the Department of Workforce Services.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    206 views1 page

    Form Employment Termination (631) - 2

    Uploaded by

    Mark Veeder
    This document is an employment termination form used by the Department of Workforce Services to collect information about an employee's termination, including employer details, employment history, reason for leaving, final pay and benefits. The form requires signatures from both the employer and employee and is to be returned to the Department of Workforce Services.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    DWS-ESD 631

    Rev. 08/2014
    Department of Workforce Services
    Employment Termination

    Case name: _________________________________________ Case number: ______________________


    Employed person: ___________________________________ SSN: ______________________________ E19019229760101:16251696
    M VEEDER
    Please use a black pen to complete form. This form is not used to determine Unemployment Insurance eligibility.

    Employer Information:
    Company name: ___________________________________________________________________________________________
    Corporate name (if different): ________________________________________________________________________________
    Company address: _________________________________________________________________________________________
    Name of supervisor or HR contact: _____________________________Phone number: __________________________________

    Employee History:
    1. Average hours the employee worked per week: ________________Hourly wage: $___________________________________
    2. Date of hire: _______________________________________Last day worked:_______________________________________
    3. Date final check available to the employee:____________________________________________________________________
    4. Gross amount (before taxes) of final paycheck:_________________________________________________________________
    5. Total gross pay (before taxes) in the month employee received their final check:______________________________________
    6. Did the employee receive severance pay or vacation pay separate from their final check?______________________________
    If so, how much?________________________________________________________________________________________
    7. Reason for leaving:  Quit (state reason) ____________________________  
    Laid off (date)_________________________
      Fired (state reason)   ___________________________  
      Leave of absence (length)________________
       
    Other (state reason)    __________________________
    8. Is this a temporary termination or furlough?  
    Yes No
     
    If yes, when is the employee expected to return to work for this company?________________________________________
    If yes, will the employee receive pay during their leave of absence?_______________________________________________
    9. Is there an option for continued medical insurance?  
    Yes No
     
    If yes, please list insurance carrier: _________________________________________Group #:_________________________
    Policy number: ________________________________ and COBRA amount: $_____________________________________
    10. Does the employee have any retirement and/or 401K benefits? Yes
      No
      If yes, how much? $ _________________
    11. Any additional comments:________________________________________________________________________________

    _____________________________________________________________________ _________________________________
    Employer Signature* Date
    *Additional verification will be required if employer does not sign form.

    _____________________________________________________________________ _________________________________
    Customer Signature Date
    Return form to employee or to Department of Workforce Services:
    _ Mail - Department of Workforce Services, Imaging Operations, P.O. Box 143245, Salt Lake City, UT 84114-3245
    Fax - Salt Lake City Area: 801-526-9500 or Toll free: 1-877-313-4717
    Equal Opportunity Employer Program
    Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.

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