Compensation Adjustment Form

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3/19 EXAMPLES

Text in this Example:

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:
Human Resources Signature:
Please List Any Additional Changes in Compensation or Benefits:
Please List Any Other Changes Not Listed Above:
Signature