Labor Lease Transaction Payroll {BWC-0519}

Labor Lease Transaction Payroll Prepared by Professional employer organization (PEO) policy number Client policy number Phone number PEO name Client name Change in lease agreement Contract termination Payroll reported by PEO on behalf of client (List by 6-month period and manual class) Payroll for lease agreement effective date Date Payroll reporting period Manual classification PEO signature Date Signature is required to indicate the above information is true to the best of your knowledge. BWC-0519 (Rev. 1/31/2012) AC-18 American LegalNet, Inc. www.FormsWorkFlow.com