[Instruction: Insert company logo/letterhead here.]
Termination Report with Witness Signature
Employee Name: _____________________________________________
Job Title: _____________ Termination Date: _______ Last Day Worked: _________
Employment Status: _________ [Instruction: Indicate full or part time, temporary, etc.]
Rate of Pay: _____________ Supervisor: _______________
Reason for Termination: __________________________________
[Comment: Employer should insert such details as whether or not such termination was
voluntary or involuntary, for cause (including any applicable details) or based on other
general factors, examples of which include workforce reduction or layoff, among others.]
Information Discussed and Documents Provided: ______________________________
[Instruction: Employer should set forth a summary of information discussed and any
documents provided to terminated employee, including any and all state or federally
required information and documents.]
I was advised of my rights, if any pursuant to applicable COBRA and unemployment benefits as
well as all applicable federal and state rights applicable to terminated employees, if any.
I have read, understand and acknowledge receipt of a copy of this document and acknowledge
the receipt of all information and documents set forth herein.
__________________________________ __________________
Signature of Employee Date
__________________________________ _______________________
-Employee Refused to Sign- Signature of Witness
Signature of Supervisor
I was present for the termination of the above-referenced employee, and hereby acknowledge the
information and documents provided to and discussed with the terminated employee is as set
forth herein.
__________________________________
Signature of Witness
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