Fill and Sign the Five Documents Employers Should Provide to Employees Separating Form

Employment Separation Notice Page 1 of 2 Basic form © James R. McDade (ver 02- 21-01) 209- 667-2300 EMPLOYMENT SEPARATION NOTICE (Issued pursuant to §1089 of the California Unemployment Insurance Code.) Employers use this form to provide notice of a change in employment relationship pursuant to §1089 of the Cal Unemployment Insurance Code. (Delete this note prior to use.) To [Name Of Former Employee] : Effective ______________, 20___, your employment with ________ _____________________________ (hereinafter, “Company”), will end or has ended for the following re ason(s): [ ] You voluntary resigned on __ _________________, 20___, and the reason you gave for resigning is ___________________________________________ _________________ ______________________________________________________________________. [ ] You were lay-off as part of a reduction in force. [ ] The Company terminated your employment because of one or more of t he following reasons: [ ] performance issues relating to the following: ___________________________ _________________________________________________________________ ________________________________________________________________ [ ] change in business needs at it relates to staffing. [ ] other: _____________________________________________ _____________. NOTE TO EMPLOYER – The provisions below are not needed for §1089 of the Cal Unemploym ent Insurance Code. Choose those provisions below that would be useful . The provisions will have to be modified to fit the employer’s actual polices and circumstances. (Delete this and all other notes prior to use.) 1. Recall from Lay-off. The Company reserves the right to make any personnel changes it desires in conformity with current laws against illegal discrimination, regardless of any s election criteria set forth in any policy. Employees have no contractual right to rely on any formal order or selection criteria for a lay- off or recall from lay-off, and the at-will employment relationship of the employee and the Company shall not be affected by any lay-off policy. 2 . Employment References and Verification . If, in the future, a request for employment verification appears to be legitimate, the Company will verify your job title, job duties, le ngth of service, and rate of pay. Any other information will only be provided if the you execute an employment information release and waiver form. If an inquiry into other employment matters is made and if you have not signe d the release and waiver, then the Company will merely inform the inquirer of t his policy and will not provide nor verify any additional information. In addition, only Brandi Rollins is authorized to provide or verify any information about current or former employees of the Company. 3 . Return of Company Property. You need to return all Company property t hat may be in your possession. The Company has reason to believe that you have the Company property listed below. Legal action may be taken against you to recover the item(s) if they are not retur ned by ________, 20___ [immediately] . [Note to employer: It is not recommended that payment of wages be conditioned upon re turn of company property. Waiting time penalties could apply if payment o f wages is not timely.] Work Files [ ] already returned [ ] will be returned Product Samples [ ] already returned [ ] will be returned Uniforms [ ] already returned [ ] will be returned Tools [ ] already returned [ ] will be returned Keys [ ] already returned [ ] will be returned Employment Separation Notice Page 2 of 2 Basic form © James R. McDade (ver 02- 21-01) 209- 667-2300 Credit Cards [ ] already returned [ ] will be returned Other: _______________________________ [ ] already returned [ ] will be returned 4 . Debts to the Company. You owe the Company $_______________ for ______________________. [ ] You agree to have this amount deducted from your last paycheck. [Note to Employers : Employer’s cannot cause net check to be less t han minimum wage; nor take more than 25 % of the net pay.] [ ] You agree to pay $____________ per month until this sum is paid in full. Simple interest at 10% shall be charged on any unpaid balance. 5 . Vacation. You had _______ days / hours of unused vacation left as of the last day of active employment. 6. Sick Pay . [Note: Address sick pay here if unused sick pay is paid out at end of employment .] 7. Final Paycheck. Your final paycheck [is attached with the notice] [has already been issued to y ou] if you were involuntarily terminated; otherwise the Company has 72 hours (less the amount of prior notice you gave before your last day of work ) to issue the check if you quit. Your final paycheck will only be issued to you unless you instruct the Company in writing to release the check to s omeone else. 8 . COBRA Notices . You will receive COBRA notices in the mail within the next few days. These notices will inform you of your options for continuing your health insurance coverage at your expense. Please inform the Company of your new address if you current address is not as follows: Address: ______________________________________________________ City / State / Zip: ______________________________________________________ COMPANY SIGNATURE ___________________________________ Date: ________________________ Company Representative FORMER EMPLOYEE’S COMMENTS [Note to Employer : Use this section if the employee is available for an exit interview and you want to try and get confirmation of the employe e’s conduct. But do not use if you want to avoid a confrontation. ] I, the undersigned, hereby acknowledge that the above information is true and accurate, except for the following (use back of form if needed) : _____________________________________________________ ____________________________________________________________________________________ I have also reported all workplace injuries, except for the following: ____ __________________________ ____________________________________________________________________________________ ______________________________________ Date: ________________________________ Former Employee’s Signature