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Company Name YOUR LOGO HERE Employee Information Compensation Adjustment Form Adjustment Information Classification Changes Signatures Additional Compensation/Benefits Information Verification of Changes Employee Name: Last First M.I. Employee ID Number: Department: Date: Effective Date: Next Review Date: Change Amount: New Salary Amount: Reason For Pay Adjustment: **NOTE - Attach all supporting documentation such as performance/probation reviews, etc. Supervisor Signature: Date: Human Resources Signature: Date: Please List Any Additional Changes in Compensation or Benefits: Please List Any Other Changes Not Listed Above: Signature Date: