Form DWS-ESD631 "Employment Termination" - Utah

What Is Form DWS-ESD631?

This is a legal form that was released by the Utah Department of Workforce Services - a government authority operating within Utah. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2020;
  • The latest edition provided by the Utah Department of Workforce Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DWS-ESD631 by clicking the link below or browse more documents and templates provided by the Utah Department of Workforce Services.

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Download Form DWS-ESD631 "Employment Termination" - Utah

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DWS-ESD 631
State of Utah
Rev. 01/2020
Department of Workforce Services
EMPLOYMENT TERMINATION
Case name:
Case number:
Employed person:
SSN:
D32319901250101
Please use a black pen to complete form. This form is not used to determine Unemployment
Insurance eligibility.
Employer Information:
Company name:
Corporate name (if different):
Payroll company (if different):
Company address:
Name of supervisor or HR contact:
Phone number:
Employee History:
1. Average hours the employee worked per week:
Hourly wage: $
2. Date of hire:
Last day worked:
3. Date final check available to the employee:
4. Gross amount (before taxes) of final paycheck:
5. Total gross pay (before taxes) in the month employee received their final check:
6. Did the employee receive severance pay or vacation pay separate from their final check?
If so, how much?
7. Reason for leaving:
Quit (state reason)
Laid off (date)
Fired (state reason)
Leave of absence (length)
Other (state reason)
8. Is this a temporary termination or furlough?
Yes
No
If yes, when is the employee expected to return to work for this company?
If yes, will the employee receive pay during their leave of absence?
9. Is there an option for continued medical insurance?
Yes
No
If yes, please list insurance carrier:
Group #:
Policy number:
and COBRA amount: $
10. Does the employee have any retirement and/or 401K benefits?
Yes
No If yes, how much?
11. Any additional comments:
Employer Signature*
Date
*Additional verification will be required if employer does not sign form.
Customer Signature
Date
Return form to employee or to Department of Workforce Services:
Mail - Department of Workforce Services, Imaging Operations, P.O. Box 143245, Salt Lake City, UT 84114-3245
Fax - Salt Lake City Area: 801-526-9500 or Toll free: 1-877-313-4717
Questions? Call - Salt Lake City Area: 801- 526-0950 or Toll Free: 866-435-7414
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling 801-526-9240. Individuals
who are deaf, hard of hearing, or have speech impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
DWS-ESD 631
State of Utah
Rev. 01/2020
Department of Workforce Services
EMPLOYMENT TERMINATION
Case name:
Case number:
Employed person:
SSN:
D32319901250101
Please use a black pen to complete form. This form is not used to determine Unemployment
Insurance eligibility.
Employer Information:
Company name:
Corporate name (if different):
Payroll company (if different):
Company address:
Name of supervisor or HR contact:
Phone number:
Employee History:
1. Average hours the employee worked per week:
Hourly wage: $
2. Date of hire:
Last day worked:
3. Date final check available to the employee:
4. Gross amount (before taxes) of final paycheck:
5. Total gross pay (before taxes) in the month employee received their final check:
6. Did the employee receive severance pay or vacation pay separate from their final check?
If so, how much?
7. Reason for leaving:
Quit (state reason)
Laid off (date)
Fired (state reason)
Leave of absence (length)
Other (state reason)
8. Is this a temporary termination or furlough?
Yes
No
If yes, when is the employee expected to return to work for this company?
If yes, will the employee receive pay during their leave of absence?
9. Is there an option for continued medical insurance?
Yes
No
If yes, please list insurance carrier:
Group #:
Policy number:
and COBRA amount: $
10. Does the employee have any retirement and/or 401K benefits?
Yes
No If yes, how much?
11. Any additional comments:
Employer Signature*
Date
*Additional verification will be required if employer does not sign form.
Customer Signature
Date
Return form to employee or to Department of Workforce Services:
Mail - Department of Workforce Services, Imaging Operations, P.O. Box 143245, Salt Lake City, UT 84114-3245
Fax - Salt Lake City Area: 801-526-9500 or Toll free: 1-877-313-4717
Questions? Call - Salt Lake City Area: 801- 526-0950 or Toll Free: 866-435-7414
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling 801-526-9240. Individuals
who are deaf, hard of hearing, or have speech impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.