Download and print PDF version HERE or complete online and submit below: Employee Status Change Pay Rate and Other Status Changes CLIENT COMPANY EMPLOYEE NAME This Change is: Permanent Once Only Number of Pay Periods Number of Pay Periods for this Change PAY RATE CHANGE (in NH employee signature is required) New Hampshire Clients: All pay changes for NH workers must be in writing and signed by the worker before the change effective date. Old Pay Rate New Pay Rate Effective Date The effective date is the FIRST DAY WORKED at the new rate. OTHER CHANGES One or more other changes may be selected Department Job Title Shift Benefit Allowance OtherOther Old Dept New Dept Old Job Title New Job Title Old Shift New Shift Old Benefit Allowance New Benefit Allowance Other Changes REASON FOR CHANGE Reason(s) for Change Merit Increase Promotion Job Re-Evaluation Demotion Shift Differential Transfer OtherOther Comments: CLIENT SIGNATURE Signature Clear Date EMPLOYEE SIGNATURE (required for NH pay rate change) Signature Clear Date If you are human, leave this field blank. Submit