EMPLOYER CONFIRMATION
PLEASE COMPLETE AND RETURN THIS CONFIRMATION TO Green Circle WITHIN 10 DAYS OF RECEIPT


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Employee: Employee SSN:
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To be completed by employer:

Date Received: Reference Number:
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Employer: Employer EIN/TIN

Check one:

The above named employee is currently employed with this employer, and deductions will start on day of , in the year .

OR

The above named employee is no longer employed with this employer.

If the employee is no longer employed with this Employer, please complete the following:

Employment Termination Date: Employee's Current employer (if known):
Employer Comments:


HR/Payroll Signature: Today's Date:
HR/Payroll Print Name: HR/Payroll Phone: