DSHS 14-438, Stop Work Instructions

Enter the client's full printed name as it should appear on the form.

Provide the client's signature to give permission for the employer to complete this form for the Department of Social and Health Services.

Enter the date the client signed this section of the form.

Enter the name of the person we can contact about this employee or the case.

Provide the full signature of the person completing and certifying this form.

Enter the date on which the person signed this form.

Enter a telephone number where the contact person can be reached, including area code and extension if applicable.

Type the full printed name of the person who signed the form.

Enter the job title or position of the person who signed the form.

Enter the full DSHS mailing address for this client, including street address, city, state and ZIP code.

Enter the DSHS phone number to contact regarding this case, including area code and any extension if applicable.

Enter the DSHS fax number for this case or contact, including area code.

Enter the DSHS case or client identification number assigned to this person.

Enter the date associated with this DSHS mailing or contact information.

Enter the full legal name of the employer or former employer (company name) as shown on payroll or official records.

Enter the employer’s postal ZIP code for the company/ex‑employer street address.

Enter the two‑letter U.S. state abbreviation or full state name where the employer’s address is located.

Enter the employer's full street address including building number, street name, and apartment or suite number if applicable.

Enter the postal ZIP code for the employer's street address.

Enter the state where the employer is located (e.g., WA or Washington).

Enter the city where the employer is located.

Enter the date the employee received the final paycheck.

Enter the amount of the employee's final paycheck before taxes.

Full legal name of the employer or client (company or individual) associated with this form.

Primary telephone number for the employer or client, including area code and any extension if applicable.

Street address or P.O. box where the employer or client receives mail.

City, state, and ZIP code for the employer or client's mailing address.

Enter the calendar date when the employee last performed work for this employer.

Enter the gross amount received for the other paycheck (before taxes) corresponding to row 1.

Enter the date when the other paycheck in row 1 was received.

Enter the dollar amount of the other paycheck received in the same month as the final paycheck, before taxes.

Enter the date that this other paycheck was received.

Enter the amount received before taxes for the other paycheck listed in row 3.

Enter the date this other paycheck (row 3) was received.

Enter the gross amount (before taxes) of the fourth other paycheck received in the same month as the final paycheck.

Enter the date the fourth other paycheck was received.

Check this box if the employee's job ended because there was a lack of work.

Check this box if the position was temporary or seasonal and the job ended for that reason.

Check this box if the employee was laid off.

Check this box if the employee was on leave (such as a leave of absence or parental leave) at the time the job ended.

Check this box if the leave noted above was paid (only applicable when 'On leave' is selected).

Check this box if the leave noted above was unpaid (only applicable when 'On leave' is selected).

Enter the dollar amount the employee is paid while on this leave. Fill only if 'On leave (e.g., leave of absence or parental leave)', 'Leave was paid' are 'Yes' (all).

Enter the date the employee is expected to return to work. Fill only if 'On leave (e.g., leave of absence or parental leave)' is 'Yes'.

Provide any other reason or additional details about why the job ended or the nature of the leave if not covered by the listed options. Fill only if 'Other (specify)' is 'Yes'.

Check this box if the job ended for a reason not listed above and provide the explanation on the 'Other' line.

Check this box if the employee is allowed to withdraw retirement/pension/401K funds (then fill in when it will be received and how much).

Check this box if the employee is not allowed to withdraw retirement/pension/401K funds.

Enter the total amount that will be withdrawn from the retirement/pension/401(k) account. Fill only if 'Retirement/pension/401K withdrawal — Yes' is 'Yes'.

Provide the date when the retirement/pension/401(k) funds will be received. Fill only if 'Retirement/pension/401K withdrawal — Yes' is 'Yes'.

Enter the short reference or confirmation code for Section 1 as shown on the form (a brief identifier placed at the end of the section header).

Type the client's written permission (for example initials or a short confirmation) indicating they give their employer permission to complete this form for the Department of Social and Health Services.

Enter the identifier or number assigned to this Section 2 entry (for example a reference number or other short ID used to identify the person completing this section).

Check this box if the employee will receive any severance pay; if checked, also complete the 'When will it be received?' and 'How much will it be?' fields.

Check this box if the employee will not receive any severance pay.

Enter the total dollar amount of the severance pay the employee will receive. Fill only if 'Severance pay — Yes' is 'Yes'.

Enter the date when the severance pay will be or was received. Fill only if 'Severance pay — Yes' is 'Yes'.

Check this box if the employee is allowed to cash out their accrued vacation or sick pay.

Check this box if the employee is not allowed to cash out their accrued vacation or sick pay.

Enter the total dollar amount the employee will receive for cashing out vacation or sick pay. Fill only if 'Can the employee cash out vacation/sick pay? — Yes' is 'Yes'.

Enter the date when the employee will receive the cashed-out vacation or sick pay. Fill only if 'Can the employee cash out vacation/sick pay? — Yes' is 'Yes'.