Employee Separation / Termination · Form HR-05

Employer information

Manager name *

Manager email * receives notices

Location *

Employer (legal name)

Employee information

Employee name *

Job title(s) * (select all that apply)

Address optional

Phone optional

Email optional

Hire date optional

Hourly rate from EM

$

Separation details

Separation type * (select one)

Last day worked *

Separation effective date *

Eligible for rehire

Reason for separation *

Disciplinary history (prior warnings or corrective action, if any)

No disciplinary records added.

Final pay

California final-wage rule. All earned, unpaid wages — including accrued, unused vacation/PTO — must be paid at separation. Involuntary terminations and layoffs are due immediately (Labor Code § 201); resignations depend on notice (§ 202). Late final pay can trigger waiting-time penalties of up to 30 days' wages (§ 203). Reimburse any outstanding business expenses (§ 2802).

Regular hours current period · uAttend

Overtime hours current period · uAttend

Vacation balance h:mm

Hour pay reg hrs × rate

$

Overtime pay OT × 1.5

$

Vacation pay balance × rate

$

Bonus payout per the structure above

$

Other owed (commission, expenses)

$

Total pay auto — all amounts

$

Final pay date

Delivery method

Final pay notes optional

Company property returned

Company property loads from the Employee Master when an employee is selected.

Outstanding items not yet returned

Benefits & system access

Assigned benefits and accounts load from the Employee Master when an employee is selected.

Separation meeting

Will the employee be present at the separation meeting? *

Yes No — mail packet & final check

Exit interview

Completed by the manager with the employee at the exit interview — answers may be typed here or wet-filled on the printed document.

Acknowledgement & signatures

Separation acknowledgments. The printed document contains the full acknowledgments the employee initials at the exit interview, including: (1) Final wages — the employee reviews the itemized amounts on this form and confirms they represent complete payment of all wages earned through the last day; (2) Hours & breaks — the employee reviews the attached timecard, confirms all hours were recorded with no off-the-clock work, and that meal and rest periods were provided or any premiums identified; (3) Work injuries — the employee confirms all work-related injuries were reported. Before signing, the employee lists any disputed or unreported items below — or writes NONE. This acknowledgment is voluntary and is not a condition of receiving final wages; it is a statement of facts, not a waiver of legal rights.

Disputed items employee lists any disputed wages, hours, breaks, or unreported injuries — or writes NONE

Employee name (print)

Employee signature date

Employee signature

Sign here with mouse or finger — or sign the printed copy

Manager / HR name (print) *

Manager signature date

Manager / HR signature

Sign here with mouse or finger