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Employee Status or Fact Change Form


Employee's Name:____________________ 
Social Security No.: ____________________ 
Date of Hire: ____________________ 
Proposed Date of Change: ____________________ 
Effective Date of Change: ____________________ 
   

AREA OF CHANGE

FROM

TO

TYPE/REASON

 

SALARY/WAGE

 

 

 

 

 

 

 

TITLE

 

 

 

 

 

 

 

TRANSFER

 

 

 

 

 

 

 

PAYROLL DEDUCTIONS

 

 

 

 

 

 

 

LEAVE OF ABSENCE

 

 

 

 

 

 

 

TERMS OF SEPARATION

 

 

 

 

 

 

 

OTHER (SPECIFY)

 

 

 

 

 

 

SPECIFIC FACTS OR STATEMENTS:
Submitted by:____________________
       Manager/Supervisor
 Date: _____________
 
 
Approved by: ____________________
       Title
 Date: _____________
 
 
Approved by: ____________________
       Human Resources Department
       Title
 Date: _____________
 
 
 
Copyright 1998 Steven M. Sack

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