Employee Terminal Benefits

EMPLOYEE TERMINAL BENEFITS AGREEMENT

This Employee Terminal Benefits Agreement documents the final compensation, benefits continuation, deductions, and obligations between the Employer and the Employee arising from the termination of employment. Completion and signature by both parties constitutes acknowledgement of the items set forth below and authorization for final payment and related administrative actions.

Employee Information

Position & Employment Details

Job Title:    Department:    Reporting Manager:

Hire Date:    Termination Date:    Reason for Termination:

Employment History (Most Recent)

Employment History (Previous)

Education

Professional References

Terminal Compensation & Benefits Summary

Final Regular Pay (for pay period ending):    Accrued Vacation Payout:

Sick Leave Payout (if applicable):    Severance Pay (if any):

Bonus/Commission Due:    Stock/Equity Treatment:

Payment Method: Direct deposit Check Wire transfer

Benefits Continuation & Retirement

Health Insurance Coverage Termination Date:

Retirement Plan / 401(k) Distribution Option Selected:

Deductions, Taxes & Withholdings

All terminal payments are subject to legally required federal, state, and local tax withholdings and deductions for benefits and authorized offsets. Estimated total deductions:

Company Property & Return Checklist

The Employee certifies that all company property has been returned or accounted for. Check returned items below:

Company laptop/charger Company mobile device Keys / access cards

Confidential documents / physical files ID badge

Release, Acknowledgements & Certifications

At-Will Employment: The parties acknowledge that employment was at-will, and nothing in this agreement alters that status unless expressly stated in writing in this document.

Equal Opportunity Statement: The Employer maintains equal employment opportunity policies and the provision of terminal benefits is administered without unlawful discrimination.

Employee Certification: I certify that all information provided in this form is true and complete to the best of my knowledge. I authorize the Employer to process the payments and deductions described herein and to take steps necessary to effectuate benefits continuation and retirement plan instructions.

By signing below, the Employee acknowledges receipt of the terminal benefits summary set forth above. Where a settlement or severance amount is specified and accepted in writing by the Employee, the Employee further acknowledges that acceptance may include a limited release of claims as described below.

Election: By checking, Employee elects to accept the severance/settlement and acknowledges the release terms above.    By checking, Employee declines the release/settlement and reserves any rights to dispute in writing.

Authorization & Background Disclosures

Authorization to Contact: The Employee authorizes the Employer and its agents to contact prior employers, benefit administrators, and financial institutions as reasonably necessary to verify information relevant to terminal benefits administration and retirement distributions.

Background Checks: The Employee understands that the Employer may rely on previously obtained background or eligibility verifications and that no additional checks are required for the administration of terminal benefits unless expressly authorized by the Employee.

I certify that all information provided is true and complete and I authorize the Employer to verify the information and to make lawful deductions from final payments for outstanding obligations.

Additional Notes (Administration Use)

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