Service Cancelation Form

Empeon

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Service Cancellation Form

Name

Email:Enter the same email address which you signed in with:

Phone Number

Company Name

Applicable company codes:For multiple companies, enter all company codes separated by a comma. IE. 9999, 9999A, 9999B

Final Pay Date to Be Processed in Empeon:

Please explain the reason

New Payroll Vendor Name?

For the terminating companies, what is final quarter that Empeon will process the quarterly returns for?

Do you require Empeon to prepare W2s for the companies that are being terminated?(Year in which the companies are terminating)

Yes (Payment of $6 ($40 mimimum base fee per company ID) per form will be required prior to release)No

Client Tax FilingFor the year in which the companies are terminating

Mid-Quarter ($250 fee to reconcile taxes, no filing)End-Quarter ($25 filing fee per Quarter-end report)Year-End (filing fees QE $25, W2 $150, Per State $150)

Please Provide Details:

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