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


Date: "MM/DD/YYYY"
Employee: Employee SSN:
"NAME" "SSN NUMBER"

To be completed by employer:

Date Received: Reference Number:
"NUMBER"
Employer: Employer EIN/TIN
"EMPLOYER"

Check one:

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

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: