HR Severance Instructions

HR SEVERANCE INSTRUCTIONS

Employee Information

Employee Name:    Employee ID:

Position:    Department:

Reporting Manager:

Termination Date:    Last Day Worked:

Severance Payment Terms

Total Severance Amount (gross):

Severance calculated as:

Lump-sum payment    Periodic installments

First Payment Date:    Final Payment Date (if installments):

Withholding and Deductions: Employer will withhold applicable federal, state, and local taxes and make authorized deductions including benefit premiums, outstanding advances, and authorized wage garnishments. Employee acknowledges taxes will be withheld from the severance payment as required by law and applicable policy.

Benefits and Continuation

Employer-provided health and welfare benefit coverage termination date:

Employer-paid benefit contributions will cease on:

Employee may be eligible to elect continued coverage at employee expense where permitted by law. Employer will provide required election notices, and any continued coverage will be subject to timely enrollment and payment of applicable premiums.

Return of Company Property

The following company property must be returned prior to final payment. Verify items returned:

Company laptop/charger    Mobile device    Building/office keys or access cards

Release, Confidentiality, and Conditions

Receipt of severance is conditioned on execution and non-revocation of the accompanying separation and release agreement. The release will include a general release of claims arising out of employment and separation, and a confidentiality obligation regarding the terms of separation and proprietary information. The release will specify any exceptions permitted by law and any required return of confidential materials.

Release executed: Yes    No

Effective date of executed release (if applicable):

Direct Deposit and Payment Method

Payment method: Check issued to employee    Direct deposit to employee account

Employment History (for HR records)

Dates employed:

Dates employed:

Education

References

Legal Disclosures and Authorization

At-Will Employment: Employee acknowledges and understands that employment status, where applicable, is at-will and may be terminated by either party at any time, subject to applicable law and any written agreement to the contrary.

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

By signing below, Employee authorizes Employer and its agents to contact prior employers, references, and third parties to verify employment history and to conduct background checks as permitted by law. Employee certifies that the information provided in this document is true and complete to the best of their knowledge.

I certify that all information provided on this form is true, accurate and complete. I understand that failure to return company property, to sign required release documents, or to comply with the conditions herein may delay or forfeit severance payments. I authorize deductions as described above and acknowledge that severance is subject to applicable taxes and lawful withholdings.

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