HTML Preview Tennessee Separation Notice page number 1.
SEPARATION NOTICE
1. Employee's Name: ________________________________________________________ 2. SSN _____________________
3. Last Employed: From: _______________ to _______________ Occupation: _____________________________________
4. Where was work performed? _____________________________________________________________________________
5. Reason for Separation:
Lack of Work Discharge Quit
If lack of work, indicate if layoff is
Permanent Temporary - Recall Date ______________
If
temporary, report any vacation pay that will be paid. Week Ending Date _____________ Amount $ ______________
If layoff is indefinite vacation pay should not be reported.
6. Employee received:
Wages in Lieu of Notice Severance Pay
In the amount of $ _________________ for period from _________________ to _________________
If other than lack of work, explain the circumstances of this separation:
NOTICE TO EMPLOYEE
YOU MAY BE INSTRUCTED TO MAIL OR FAX THE SEPARATION NOTICE TO TENNESSEE CLAIMS OPERATIONS IF YOU FILE A
CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS.
NOTICE TO EMPLOYER
Within 24 hours of the time of separation, you are required by Rule 0800-09-01-.02 of the Tennessee Employment Security Law
to provide the employee with this document, properly executed, giving the reasons for separation. If you subsequently receive a
time sensitive request for separation information for the same information please give complete information in your response.
LB-0489 (Rev. 06-15) RDA 0063
Number shown on State Quarterly Wage Report (LB-0851) and
Premium Report (LB-0456)
(mm/dd/yy)
First Middle Initial Last
(mm/dd/yy)
(mm/dd/yy) (mm/dd/yy)
(mm/dd/yy)
Employer's Name:
Address where additional information may be obtained: Employer's Telephone Number:
Employer's Email Address:
I certify that the above worker has been separated from work and the information furnished hereon is true and correct. This report
has been handed to or mailed to the worker.
__________________________________________ _________________________ ____________________
Employer's Account Number:
Signature of Official or Representative of the Employer
who has first-hand knowledge of the separation
Title of Person Signing Date Completed and Released
to Employee
STATE OF TENNESSEE
DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF EMPLOYMENT SECURITY
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