Employee Layoff Package

EMPLOYEE LAYOFF PACKAGE

Personal Information

Position Information

Layoff Details

Effective date of separation:

Reason for separation (select all that apply):

Severance and Final Pay

Severance payment offered (gross):

Severance payment schedule or method:

Final paycheck date (including accrued wages):

Accrued paid time off payout (gross):

Benefits and Continuation

Benefits continuation period offered:

Employee responsibility for continued premiums and enrollment information will be provided in writing by the Benefits Administrator. Contact HR representative: Phone:

Outplacement Assistance

Return of Company Property

The following company property must be returned no later than the effective separation date. Indicate items returned or note outstanding items.

Release and Severance Agreement (If Applicable)

In consideration of the severance payments and benefits described above, and excluding obligations that cannot be waived by law, the employee agrees to release and forever discharge the company and its affiliates, officers, directors, employees and agents from any and all claims, demands, actions, causes of action, suits, liabilities, costs and expenses arising from any act, omission or employment relationship through the effective date of separation. This release includes, but is not limited to, claims related to employment, termination, discrimination, and compensation to the extent permitted by law.

Employee acknowledges that acceptance of severance is voluntary, that consideration is in addition to anything owed by law, and that the employee has been afforded a reasonable period to review this package prior to signing. If this package contains a revocation period, the employee has the stated revocation period to withdraw acceptance in writing as set forth below.

Unemployment Benefits and Taxes

Employee may be eligible to apply for unemployment benefits in accordance with applicable law. Severance payments and other separation payments may be subject to taxes and withholdings as required by law. The company will report and withhold taxes where required and will provide applicable tax forms at year end.

At-Will Employment and Equal Opportunity

Nothing in this layoff package alters the at-will nature of employment where applicable. Either the employee or the company may terminate the employment relationship at any time, with or without cause or prior notice, unless otherwise expressly provided in a separate written agreement signed by an authorized company representative.

The company is an equal opportunity employer. Layoff decisions are made without regard to protected characteristics and in accordance with applicable employment laws.

Authorization to Contact and Background Verification

The employee authorizes the company and its agents to contact former employers, references and service providers for the limited purpose of verifying employment history, processing separation benefits, and administering unemployment claims. The employee further authorizes the company to obtain such records as are necessary to effectuate separation and benefits administration.

Applicant Certification

I certify that the information I have provided in this Employee Layoff Package is true, complete and accurate to the best of my knowledge. I acknowledge receipt of the layoff information and any separation payments described herein, subject to the terms of any executed release. I understand that by signing this package I am acknowledging receipt of these materials and, if applicable, agreeing to the release and severance terms selected above.

Employment History

Prior Employer 1

Prior Employer 2

Education

References

Reference 1

Reference 2

Reference 3

Employee Acknowledgment

By signing below, the employee acknowledges receipt of this Employee Layoff Package, understands the terms described herein, and certifies that the information provided in this document is complete and accurate. If the employee has indicated acceptance of severance above, signing below constitutes acceptance of the release and severance terms subject to any applicable revocation period.

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