HR LLC Ownership Update Form

HR LLC OWNERSHIP UPDATE FORM

Use this form to notify Human Resources of a change in ownership for an LLC in which an employee holds an ownership interest. Complete all sections that apply and attach supporting documentation where indicated. Incomplete submissions may delay processing of payroll, benefits, or compliance actions.

Personal Information

Address: Phone: Email:

Position Information

Current employment start date:    Current annual salary / pay rate:

LLC Ownership Details

Federal Tax ID / EIN (if available):    Effective date of ownership change:

Type of change: Transfer/Sale Gift/Inheritance Internal Reallocation Other

Ownership Composition — Prior and New

Prior ownership percentage held by employee:    New ownership percentage held by employee:

Operating Agreement Transfer/Sale Agreement Trust/Probate Documents Other (describe below)

Payroll, Benefits & Tax Withholding Impact

Will this ownership change require updates to payroll/benefits or tax withholding? Yes No

Employment History

Education

Professional References

Legal Disclosures & Authorizations

At-Will Employment: Employee acknowledges that employment status and terms remain governed by the employer's at-will employment policy unless expressly modified in a separate written agreement signed by an authorized company representative.

Equal Opportunity: Employer is an equal opportunity employer. Decisions related to employment, benefits, and job duties are made without regard to protected characteristics, subject to applicable law.

Authorization to Verify: By signing below, Employee authorizes the employer and its agents to verify any information provided in this form, including contacting previous employers and reviewing documentation related to ownership and tax status. Employee further consents to background checks as required for compliance purposes.

Consent to Update Records: Employee acknowledges that submitting this form may result in updates to payroll, tax withholding, benefits, or other personnel records. The employee understands responsibility to provide accurate information and to timely notify HR of any further changes.

Certification: I certify that all information provided on this form and any accompanying documentation is true, complete, and correct to the best of my knowledge. I understand that falsification or omission of material facts may result in disciplinary action, up to and including termination, and may have legal consequences.

Background check authorization: I consent to background checks and verification I do not consent

Additional Notes

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