This is a checklist that a company can provide terminated employees requiring their
certification that they have completed all necessary tasks in lieu of separation from the
company. The employee is reminded to return the employee identification badge, keys,
key cards, software, company cell phones, company credit cards, and much more. This
checklist is ideal for small businesses that want to obtain employee certification that
they returned all company property and completed all necessary separation tasks.
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1. Text in Gray font throughout the form
should be replaced with appropriate
Termination Certification specific information, and the blanks
and bracketed words deleted.
Exit checklist for separating employees. 2. Once complete, highlight all text in the
document and change the font color to
3. Delete this instructional text box.
Please review each of the line items below and initial next to each
if you have either received the item/documentation or have returned the item indicated.
If you have never received the indicated materials, please initial in the appropriate column.
If you have questions or comments regarding any of the indicated materials, please explain in the
comments section at the bottom of the form, referring to the line item number.
Once you have completed the form, sign, date and return it to the attention of ___ [Contact Name
Your completed Certification must be returned no later than ___ [Date].
Employee Name: _____________________________________________________________
Employee Number: ________________ Date of Termination:______________________
Leaving the Position of: _______________________________________________________
Initials Issued Material / Item / Documentation
Items to be returned:
Employee Identification Badge.
Keys, Key Cards or Access Cards, including desk, file cabinet keys.
Company owned manuals, books, journals, or subscriptions.
Company credit/charge card.
Company cell phone and all accessories.
Company computer equipment and all accessories.
Company owned home office equipment (fax, scanner, etc.)
Company issued uniforms.
Expense reports (must be submitted within thirty days).
Reimbursement of relocation or other sign-on bonus (prorated) (must be
submitted within sixty days).
Passwords to company systems provided to immediate supervisor.
Relinquishment of corporate housing (must vacate within thirty days).
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Repayment of any amounts advanced to employee (must be submitted within
Parking structure access card(s).
Company sponsored gym membership cards, or other company sponsored
retail shopping discount cards.
Items / Materials I am to receive:
Final paycheck that includes vacation pay-out (if applicable).
A copy of Termination Certificate.
Information relative to my rights to continue health benefits via COBRA.
Information relative to the distribution or payout of 401K plan.
Address Update Form (should be completed and returned).
Permission to provide references to future employers (should be completed
Departing Employee Certification:
I have completed this checklist to the best of my knowledge and ability, and have returned all
items indicated above by my initials.
Employee Signature Date
The above-referenced employee signed this Termination Certification in my presence. A copy of
the completed certification has been provided to the departing employee.
Manager Signature Date
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