CDS Termination of Employment Form

CDS Termination of Employment
Employer Name (Client or Legally Designated Employer)*
If the employer is the client, but the client uses a Designated Representative for signing purposes, please put client name here.
Employer Email Address*
The confirmation and copy of this form will be sent here.
Employee/Attendant Name*
This is the person whose employment is being terminated.
Program*
Termination Date*

MonthDayYear
Date
Last Date Actually Worked*

MonthDayYear
Date
Date of Last Issued Pay Check*

MonthDayYear
Date
Other than the Final Check, is additional pay due on the Termination Date Listed Above?*

YESNO
If YES, Check One*

Regular PayBonus PayOther
If YES, Check One*

Regular PayBonus PayOther
NOTE: If a Final Check is due, a completed Timesheet must be submitted to HRA via the electronic timesheet form 1 (one) working day before the Termination Date listed above.
Reason for Termination*
LAY OFF*

Reduction of AttendantsEliminated PositionShortage or Loss of Funds
VOLUNTARY RESIGNATION*

Found Another JobContinuing with EducationPersonal ReasonsDissatisfied with Job DutiesDissatisfied with PayDissatisfied with HoursJob AbandonmentOther
INVOLUNTARY TERMINATION*

Poor Work PerformanceUnable to Follow DirectionsRefused Job TaskAbsenteeism/PunctualityPoor AttitudeInappropriate BehaviorGross MisconductOther
NOTE: Involuntary Termination must be supported by uploading Employee Performance Appraisal (Form 1732) or proper disciplinary documentation.
Supporting Documentation*

Cancelof
Comments/Instructions
Employee/Attendant Signature

Clear
Employer Signature*

Clear
Date*

MonthDayYear
Date
Submit Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: