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Get WA DSHS 14-438 2001

On to my employer to complete this form for the Department of Social and Health Services. SIGNATURE DATE PLEASE PRINT YOUR NAME HERE NAME OF COMPANY COMPANY ADDRESS: 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.

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