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Page 2 of 2 Effective: April 1, 2026

THE FOLLOWING SECTION TO BE COMPLETED OR VERIFIED BY EMPLOYER:

Employment Detail: Please provide the following information. Employee Name: Job Title:

Employment Status: Complete the line that is applicable. Is Employee Active: Date of Employment: Was Employee Terminated: Date of Termination:

Frequency of Pay: Place an “X” in the space that is applicable. Hourly Weekly Bi-Weekly Bi-Monthly Monthly Annually Other

Pay Information: Please provide current (active employees), future (new hires), or past information (recently terminated) for employee. Last (4) Pay Periods # of Hours Worked Hourly Pay Rate # of Overtime Hrs. Gross Pay Date of Check Year to Date Earnings Is Overtime Regularly earned? Are you aware of any other compensation this person may be receiving at this job that is not listed above? If yes, explain.

I certify that, to the best of my knowledge and belief, the information provided on this form is true and accurate.

Employer’s Signature Employer’s Printed Name

Employer’s Phone Number Fax Number