Provider Wage Supplement Staff Change – Tarrant County CCMS

Provider Wage Supplement Staff ChangeLogan Crouch2021-11-16T17:11:08-06:00

Tarrant TRS Supplement Wage Program - Staff Change

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PRIM ID
Basic Information
Provider Name*
License Number*
Your Name*
First Last
Your Title*
Your E-mail*
Enter Email Confirm Email
Your Phone Number*

Employee's Information
Employee's Name*
First Last
Employee's Title*
Employee's Date of Birth*
Employee's Last 4 digits of SSN*
Employee's Hire Date*
Employee ID
(If employee has one)
Employee's Home Address*
Street Address City ZIP / Postal Code

Change Information
Employee Change Type*
- New Hire
- Position change
- Rate of Pay
- Extended Leave
- Resignation
- Termination
- Other
Employee's New Title
Employee's Average Hours Worked Each Week*
Employee's Hourly Pay/Salary*
Estimated number of days needed for leave
Employee's End Date*
Additional Change Notes

Review Information
Summary

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06/02/2023
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I certify that all information provided on this form is true and accurate. I understand that giving false information may constitute fraud and could result in prosecution.
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