Practice Name
*
Full Name of Dismissed Employee
*
First Name
Last Name
Last Date of Work
*
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Did you approve the dismissed employee's time in Gusto?
*
Yes
No
If Employee has Health Insurance, should we withhold full month's premium?
*
Yes
No
Did employee choose to leave?
*
Yes
No
Reason for Dismissal if YES
Please Select
Career Advancement
Compensation
Leave of ABSENCE
Personal Reasons
Relocation
Return to School
Type of Work
Reason for Dismissal if NO
Please Select
Attendance
Layoff
Location
Performance
Position Eliminated
Seasonal
Submitter Name
*
First Name
Last Name
Submitter Email
*
example@example.com
Notes
Submit
Should be Empty: