DSHS 14-438 (REV. 07/2015)
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
TELEPHONE NUMBER
PRINT YOUR NAME HERE
POSITION / TITLE