Preview Payroll Separation Notice

Employee Name: ______________________________________________________________

Employee ID Number: __________________________________________________________

PAYROLL SEPARATION CHECK REQUEST FORM

Use this form only if the employee will be receiving a FINAL PAYCHECK.

Campus Payroll

BOX0812•eFax415/920-2513

1855FolsomStreet,Ste.425

SanFrancisco,CA94143-0812

payrollpr[email protected]

EC Form v6.0 040710

CalifornialawrequiresthattheUniversityremitnalpaymentofallwagesowed,includingvacationleaveandcompensatorytimewithin72hoursofthedateof

separationforanyemployeewhovoluntarilyresignswithoutadvancenotice.Employeeswhoseparateinvoluntarilyorvoluntarilywithmorethan72hoursnotice

mustreceivepaymentatthetimeofseparation.ThisformaddressestheinformationneededfortheCampusPayrollOfcetomeetthemandateddeadlines.

This completed form must be submitted to Campus Payroll via the secure fax number provided below or as an email attachment to the address below

at least 5 days prior to employee separation.

Type of Separation:

oInvoluntary

oVoluntarywithatleast72hournotice

oVoluntarywithlessthan72hournotice

Separation Information (ll in blanks):

LastDayonPayStatus:_______________________________

SeparationDate:______________________________________

ReasonCode:________________________________________

DateOLPPSUpdated:_________________________________

Final Pay Information (complete below):

Pay Disposition (choose only one):

oDirect Deposit (only if employee is already setup for Direct Deposit in OLPPS)

oProduce Paper Check

o Check

Pick-up Notification (Pick-Up location is Mission Center Building):

 oCheck is to be picked up by EMPLOYEE (Voluntary Separation ONLY/Must Show Photo ID)

 o Check is to be picked up by DEPARTMENT

 IfDEPARTMENT,pleaseprovideDepartmentContactName&PhoneNumber:

Name: ______________________________________ Number: __________________

 oCheckistobeMAILEDbyFedEx(USPSisnotallowed):

Name: __________________________________________________________________

Address: ________________________________________________________________

City/State: _______________________________________ ZIP: ___________________

FedEx Account Number (required): ____ ____ ____ ____ ____ ____ ____ ____BBBB

Prepared By: __________________________________________ Approved By: ________________________________________

Department: _______________________________________________________

Phone Number: ____________________________________________________

Date: ______________________________________________________________

PeriodEndDate:    TitleCode:     Rate:

    DOS:      Hours/%:

PeriodEndDate:    TitleCode:     Rate:

    DOS:      Hours/%:

Period

EndDate:    TitleCode:     Rate:

    DOS:      Hours/%:

* Please see instructions on following page

Remaining Accrual Owed to Employee

Leave Type* Current Balance Prior Period Accrual Current Period Accrual Total Hours Paid

Vacation Leave

Sick Leave N/A

Comp Time N/A N/A

Please select code from pulldown list

BU / Fund / Dept ID / Project / Fn / Flex / Sub:

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