| 3.
Termination for Incapacity - 40 hour week |
|
|
|
|
|
|
|
| INSTRUCTIONS FOR COMPLETION: |
|
|
|
| 1.
Complete Shaded Grey areas only |
|
| 2.
Complete Tombstone Data |
|
| 3.
Complete for Termination for Incapacity - |
|
| 4.
Complete Leave Without Pay - for Leave > 3 months for Relocation of
Spouse, |
|
| Personal Leave and Care &
Nurturing |
|
| 5.
Complete separate row for each period where AWW differs |
|
| 6.
To Save - Click on File - Hit "SAVE AS" - type in employees
last name and hit Save |
|
| 7.
1 copy for file - 1 copy to employee |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| NAME |
|
|
|
CPC ID# |
|
|
| P/L # |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Severance
Payable from: |
|
to |
|
|
|
|
(mm/dd/yy) |
|
(mm/dd/yy) |
|
|
| RETIREMENT
or DEATH or |
|
|
|
|
| TERMINATION for Incapacity (excluding
Discipline) |
|
| |
|
|
|
| 1ST DATE |
LAST DATE |
ASSIGNED |
# OF |
Full Time |
# OF DAYS |
# OF YEARS |
|
| (mm/dd/yyyy) |
(mm/dd/yyyy) |
WW |
DAYS |
Daily Equiv. |
Full Time Equiv. |
Full Time Equiv. |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| LEAVE WITHOUT PAY > 3 MONTHS (for Relocation of
Spouse, |
|
| Personal
Leave and Care & Nurturing) |
|
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| |
|
|
0 |
0.00 |
0.00 |
0.00 |
|
| TOTAL
FULL TIME EQUIVALENT YEARS |
|
0.00 |
|
|
| |
|
|
MAX ALLOWED (completed yrs.) |
|
|
0 |
|
|
0.00 |
| YEARLY SALARY = |
|
|
SEVERANCE
DUE ON RETIREMENT |
$0.00 |
|
|
|
|
|
|
|
|
|
|
|
|
