Stop Work Form PDF Details

Navigating the complexities of employment and benefit adjustments necessitates careful documentation, as exemplified by the Stop Work form provided by the Department of Social and Health Services (DSHS). Employed as a crucial instrument, this form is designed for instances where an individual's employment status undergoes a change, requiring them to report this transition to DSHS. Primarily, it entails two distinct sections that need to be filled out by both the employee and the employer respectively. Initially, clients are required to complete the first part of the document with their personal information and express consent for their employer to fill in the remaining details. This encompasses the company name, address, and the client's identification data. Subsequently, the employer contributes by specifying the last working day, final paycheck amount, reasons for employment cessation, and any potential severance or benefits due to the employee. The comprehensiveness of this form ensures that all parties involved have a clear and transparent record of employment termination, facilitating a smoother transition in the adjustment of the client's benefits with DSHS. This meticulous approach aids in preventing discrepancies and ensures that the welfare of the client is maintained through accurate and timely communication between the employer, the employee, and DSHS.

QuestionAnswer
Form NameStop Work Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdshs printable forms printable, wa stop work form, work form, washington dshs stop work form

Form Preview Example

Stop Work

DSHS MAILING ADDRESS

DSHS PO BOX 11699 TACOMA, WA 98411-9905

DSHS PHONE NUMBER

DSHS FAX NUMBER

 

888-338-7410

 

 

CASE / CLIENT ID NUMBER

DATE

 

 

Section 1: Client, fill out this section before taking it to your job that ended.

By signing here, I give my permission to my employer to complete this form for the Department of Social and Health Services.

CLIENT’S SIGNATURE

DATE

CLIENT: PLEASE PRINT YOUR NAME HERE

NAME OF COMPANY / EX-EMPLOYER

COMPANY / EX-EMPLOYER STREET ADDRESS

CITY

STATE

ZIP CODE

Section 2: The person in the company who knows the employment and pay information fills out this section.

1.

What was the last date that the employee worked?

 

 

 

 

 

 

 

 

 

 

 

2.

Amount of final paycheck (before taxes): $

 

 

 

 

 

Date received:

 

 

List the amounts (before taxes) and dates received for other paychecks received in the same month as the

 

final paycheck:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMOUNT RECEIVED (BEFORE TAXES) DATE RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Why did this job end?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lack of work

Job was temporary/seasonal

 

Laid off

 

 

 

 

 

 

 

 

On leave (such as leave of absence or parental leave). Is it:

Paid

 

 

Unpaid

 

 

If paid, how much is the employee paid: $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

When is the employee expected to return?

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Will the employee receive any severance pay?

yes

 

No

 

 

 

 

 

 

 

 

 

IF YES: When will it be received?

 

 

How much will it be?

$

 

 

 

5.

Can the employee cash out vacation/sick pay?

yes

 

No

 

 

 

 

 

 

 

 

 

IF YES: When will it be received?

 

 

How much will it be?

$

 

 

 

6.

Can the employee withdraw retirement/pension/401K funds?

yes

No

 

 

 

 

 

IF YES: When will it be received?

 

 

How much will it be?

$

 

 

 

Please provide the following in case we need to contact you:

 

 

 

 

 

 

 

 

 

 

SIGNATURE

DATE

TELEPHONE NUMBER

PRINT YOUR NAME HERE

POSITION / TITLE

DSHS 14-438 (REV. 07/2015)

How to Edit Stop Work Form Online for Free

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It is straightforward to fill out the pdf with this practical tutorial! Here's what you need to do:

1. To start off, once completing the work form pdf, start with the page containing following blank fields:

Part no. 1 of completing wa stop work

2. Just after this section is done, go to type in the applicable information in these - Why did this job end, Lack of work, Job was temporaryseasonal, Laid off, On leave such as leave of absence, Paid, Unpaid, If paid how much is the employee, When is the employee expected to, Other, Will the employee receive any, yes, IF YES When will it be received, How much will it be, and Can the employee cash out.

Paid, On leave such as leave of absence, and How much will it be inside wa stop work

It's simple to make an error when filling in your Paid, hence ensure that you take a second look before you'll send it in.

3. The following segment is related to Can the employee withdraw, yes, IF YES When will it be received, How much will it be, Please provide the following in, PRINT YOUR NAME HERE, DSHS REV, DATE POSITION TITLE, and TELEPHONE NUMBER - type in these blanks.

IF YES When will it be received, DATE POSITION TITLE, and Please provide the following in in wa stop work

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