Change of Status Form by A9Not2G

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									                                  Change of Status

Employer Name:


Employer Submission Date:



Employee Information:

First Name                   Middle Name or Initial   Last Name




Change Of Status:                                     (Name, Address, W4, Rate, or Termination)



Before:




After:



 Voluntary or Involuntary?
      (if applicable)


   Rehire? (if applicable)



Notes or Reason:

								
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