Employee Status Change

Pay Rate and Other Status Changes

This Change is:

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.
The effective date is the FIRST DAY WORKED at the new rate.

OTHER CHANGES

One or more other changes may be selected

REASON FOR CHANGE

Reason(s) for Change

CLIENT SIGNATURE

EMPLOYEE SIGNATURE (required for NH pay rate change)