The Commonwealth of Massachusetts					    Telephone (617) 727-3777
Human Resources Division, Civil Service Unit			Toll Free within MA: 1-800-392-6178
One Ashburton Place, Room 301, Boston, MA 02108					TDD: (617) 727-7583

Absence and Termination Notice/Form 56

City (Town): SPRINGFIELD     	Date:       

Name:       	   Social Security Number:     

Department:      	Last Date of Paid Employment:     

Civil Service Title:      

Be sure complete information is given and instructions followed.  Otherwise, the form will be returned.  Indicate absence or termination of employment by checking one of the following terms:

 Leave of Absence (Indicate duration and reason)
 Entered Military Service
 Illness (Personal)
 Illness (Family)
 Injury
 Explanation of Temporary transfer
 # Expiration of Temporary Employment	#Corres/Req. Number     
 # Expiration of Provisional Employment	#Corres/Req. Number     
 *Discharged (Indicate reason, Section 41)
 *Suspended for Cause (Indicate duration and facts in detail, Section 41)
 f*Position Abolished, Section 41, Section 39
 f*Layoff-Lack of work or money, Section 41, Section 39
 Terminated during probationary period, Section34
 Terminated-Did not return to work following approved leave of absence, Section37
 Permanent Separation-Unauthorized Absence, Section38
Resigned-List effective date, if other than last date of PAID employment (If member of fire or police department, state whether or not charges were pending)
 Resigned-Illness
 Retired
 Pensioned
Died

Name and Title of Appointing Authority:       
		(Please print)

Signature of Appointing Authority: ______________________________________________________________

The Auditor (Accountant) and Treasurer have been notified of the above absence or termination.  
*I hereby certify that the provisions of Massachusetts General Law, Chapter 31, Section 41 have been complied with in the case of this employee.  
f This action is in accordance with seniority in service.
#Over

Employee’s address should be noted under REMARKS.
Any necessary REMARKS may be made on the reverse side.

INSTRUCTIONS

It is not necessary to notify this office or to file one of these forms in the case of illness, injury or leave of absence unless the employee has been absent without pay for over one month.  (Leave of absence can be granted only to a permanent employee who has served a probationary period except in certain cases, that is, for personal illness, military leave, educational leave or to a person holding elective State Office or elected by the people to the office of Mayor.)  All other absences and terminations must be reported immediately on this form.

Absence and Termination Notices are not necessary for emergency employees.  If an emergency appointee works less than the period originally approved, a letter stating the number of days employed under this appointment will be sufficient.

#When reporting termination under this term, not beside Corres.  Number the correspondence reference number on which the employee was appointed.  DO NOT USE THIS FORM in the case of a permanent employee who is terminating temporary or provisional appointment or promotion in the same unit in which employed on a permanent basis and who is resuming permanent status.  Municipalities should report this action by letter (in quadruplicate-quintuplicate if local official requires a copy) listing the permanent Civil Service title, salary and date permanent status was resumed.

DATE RECEIVED BY THE 
HUMAN RESOURCES DIVISION	REMARKS (Continued from other side, if necessary)